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Orthotic Service Referral Form

Referral details

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Location(Required)

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Service(Required)

Referral date(Required)

Orthotic Service(Required)

Inpatient referral

Outpatient referral

Outpatient

Location / Hospital(Required)

Please specify outpatient location(Required)

Please specify inpatient location(Required)

Specify ward(Required)

Specify department(Required)

Side(Required)

Left

Right

Bilateral

Axial

Primary diagnosis(Required)

Note any amputations/active wounds

Bracing objective(Required)

Describe the functional goal of the brace

Date of amputation (if applicable)

Patient details

Patient title

First name(Required)

Last name(Required)

Ethnicity(Required)

Patient NHI(Required)

Date of Birth(Required)

Patient gender

Please specify gender

Is an interpreter required?

Yes

Interpreter language

Please specify interpreter language

Contact phone number (mobile preferred)(Required)

Address

Street Address Suburb City Region Postal Code Country

Medical centre name

GP name

Alternative contact details

Alternative contact person - First name

Alternative contact person - Last name

Relationship to patient

Please specify relationship

Contact mobile number(Required)

ACC Information

Is this patient funded by ACC?(Required)

Yes

Case Manager(Required)

Claim number(Required)

Date of injury(Required)

Health considerations

Relevant medical history (tick all that apply)

Health Considerations

Please specify other health considerations

Are mobility aides used?

Yes

Please specify mobility aides(Required)

Does the patient have a current infectious disease?(Required)

Yes

Unknown

Please specify infectious disease

Are there any safety considerations or support needs we should be aware of for this patient?

e.g Support with communication, factors that cause distress etc.

Yes

Please check all that apply(Required)

Select any that apply and make a note in the comment box

Support with communication and understanding is needed

There are factors that may cause distress or discomfort (e.g. environment, procedures, or interactions)

There are considerations that may impact safe care delivery (e.g. history of escalating behaviour, requires a support person, close monitoring)

There are specific approaches or strategies that work well (e.g. best approaches, things to avoid, successful de-escalation techniques)

Other

Please specify other safety considerations or support needed(Required)

Comment

Referrer Details

Referrer - First name(Required)

Referrer - Last name(Required)

Role

Phone(Required)

Email(Required)

Referring hospital, department & ward

Same as inpatient ward/department

Other

Referring clinic(Required)

Attach files

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 10 MB, Max. files: 3.

Please send me an email confirmation of this referral

Yes