OF Genetic Paediatric Service King Edward Memorial Hospital for Women Agnes Walsh House 374 Bagot Road, SUBIACO WA 6008 Telephone: (08) 6458 1625 Facsimile: (08) 6458 1685 Email: PAEDIATRIC REFERRAL FORM PLEASE FAX COMPLETED REFERRAL FORM TO (08) 6458 1685 PATIENT DETAILS (please affix patient sticker if possible) Name: URN: Address: DOB: Suburb/Postcode: Telephone: Interpreter required: Language: TYPE REFERRAL (please indicate priority) Reason/s for referral Ward consult diagnosis Urgent (to be seen within 2 days) management implications Non-urgent (to be seen within 3-5 days) testing of siblings/family planning Outpatient appointment parental anxiety / support needs Urgent (to be seen within 4-6 weeks) other, please specify ________________________________ Non-urgent REASON FOR REFERRAL: **PLEASE COMPLETE BOTH SIDES OF THIS FORM**
Genetic Paediatric Service King Edward Memorial Hospital for Women Agnes Walsh House 374 Bagot Road, SUBIACO WA 6008 Telephone: (08) 6458 1625 Facsimile: (08) 6458 1685 Email: PAEDIATRIC REFERRAL FORM PLEASE FAX COMPLETED REFERRAL FORM TO (08) 6458 1685 PATIENT DETAILS (please affix patient sticker if possible) Name: URN: Address: DOB: Suburb/Postcode: Telephone: Interpreter required: Language: TYPE OF REFERRAL (please indicate priority) Reason/s for referral Ward consult Urgent (to be seen within 2 days) Non-urgent (to be seen within 3-5 days) Outpatient appointment Urgent (to be seen within 4-6 weeks) Non-urgent diagnosis management implications testing of siblings/family planning parental anxiety / support needs other, please specify ________________________________ REASON FOR REFERRAL: **PLEASE COMPLETE BOTH SIDES OF THIS FORM**
GPS-referral-form.docx