Incomplete referral form may result in processing delays and impact on the client’s care coordination
Please sign and submit the completed form to info@blackswanhealth.com.au or fax to 9201 0033
Please refer to the Black Swan Health website for eligibility and exclusion criteria
Date of referral: <TodaysDate>
1. CLIENT DETAILS	
Title: <PtTitle>   Gender: <PtSex>
D.O.B: <PtDoB> *client must be over 18 to be eligible
Last Name: <PtSurname>  First name: <PtFirstName>
Access issues: <Any access issues?>
Address: <PtStreet>
Suburb: <PtCity>  Postcode: <PtPostcode>
Mobile: <PtPhoneMob>  Home: <PtPhoneH>  Email: <PtEmail>
Emergency / Next of Kin name: <NOKName> Phone: <NOKContact>
Is the client of Aboriginal and/or Torres Strait Islander descent? <Aboriginal and/or Torres Strait Islander descent?>

2. REFERRAL INFORMATION	
Referrer: <Referrer Details>
Referrer Name: <Referrer Name (skip if GP)>   Position: <Referrer Position (skip if GP)>
Address: <Referrer Address (skip if GP)>   Suburb: <Referrer suburb (skip if GP)>   Postcode: <Referrer Postcode (skip if GP)>
Phone: <Referrer Phone (skip if GP)>   Fax: <Referrer Fax (skip if GP)>   
Email: <Referrer Email (skip if GP)>

3. GP DETAILS
GP’s name: <DrName>
GP’s practice: <Practice>
Address: <DrStreet>
Suburb: <DrCity>  Postcode: <DrPostcode>
Phone: <DrPhone>   Fax: <DrFax>
Email: <DrEmail>

4. REFERRAL INFORMATION	
Confirmed respiratory diagnosis (please tick one for eligibility to the Respiratory Services Program)
<Confirmed respiratory diagnosis>
Respiratory Physician (if different from referrer: <Respiratory physician (if different from referrer)>
Lung Function (attached results preferred):
FEV 1(L): <Lung Function - FEV 1(L) (or attach):>
FEV 1(% Pred): <Lung Function - FEV 1(%pred) (or attach):>
FVC (L): <Lung Function - FVC (L) (or attach):>

Client’s current respiratory condition:
Oxygen Therapy: <Oxygen Therapy>   Flow Rate: <Oxygen Therapy - Flow Rate:>   Hours per day: <Oxygen Therapy - Hours per day:>
CPAP / BIPAP: <CPAP / BIPAP>   Details: <CPAP / BIPAP details:>

Other relevant medical condition(s):
<Other relevant medical condition(s)>
Other: <Other releveant medical condition, please specify:>

Current Treatment: <Current Treatment>
Current Medications (or attach): <SelectedRx>
Allergies: <Reactions>

Note: 
-  Please attach the GP Management Plan and/or Team Care Arrangement if available
-  Client will be triaged to assess suitability for the Healthy Lifestyle Program or Respiratory Linkage	
 
5. CONSENT TO REFERRAL – please select one of the two options below.  Black Swan Health is only able to accept this referral where the client  has consented to the referral, either verbally or in writing
[  ]   I consent to be referred to Black Swan Health

Client signature: _____________________________   Date:  ___ / ___ / _____

Print Name:            _____________________________  

[  ]   My client has been assessed and meets the eligibility criteria for a referral to Black Swan Health 
[  ]   I have obtained verbal consent from the client / legal guardian to refer and provide their personal health information to Black Swan Health for further assessment	

Referrer's signature: _____________________________   Date: ___ / ___ / _____

Print Name:        _____________________________                                                         	
OFFICE USE ONLY – leave blank
Unique client number (Black Swan Health to generate):  _________________________________