Referral Form –Allied Health Services (Metro)
360 Health + Community
Patient/Client Details	
Patient Name:                                                                                   
DOB:	

  Gender: M       F   
  Other:___________	
Patient Address:
	
Date of Referral:   	Phone home: 	Mobile:	
Healthcare/Pension Card?     

  Y            N	Card Number: 	Expiry Date:	
Medicare Card Number:	Expiry Date:	

ATSI registered?   Y         N	
Referring GP  /  GP Contact Details 	Referring Allied Health Details	
GP Name:
Practice Name:
Practice Address:	Name:
Practice/Organisation
Address: 
	
Please indicate main presenting condition and attach summary sheet of medical history, medications & relevant pathology	
Cardiovascular

 Renal

 Type 2 Diabetes  - Date of Diagnosis:_____________

 Respiratory 	

Musculoskeletal 

Other condition please specify 
___________________________

High risk of chronic conditions 	
Service Required –  Please ensure appropriate documents are attached 	
Allied Health Services - Attach GPMP/TCA & Allied Health Referral (EPC)	Patient requires other services	

Diabetes Educator      

Exercise Physiologist 

Dietitian  

Occupational Therapist

Speech Pathologist 

Healthy Lifestyle Program 
 (High Risk Waist Measurement >88cm females;  >102cm males -  BMI > 30kg/m2)

Type 2 Diabetes Exercise group

Is it safe for this individual to participate in light-moderate intensity exercise?         Yes          No	
360 Health + Community will, where appropriate, direct your patients to other 360 programs and allied health professionals to assist the patient to make lifestyle changes.	
Please fax to 360 Health + Community on 9279 8221 or email to referrals@360.org.au