MARATHON HEALTH PRIMARY HEALTH SERVICES CHRONIC DISEASE TEAM – REFERRAL
	Please return completed referral via argus ahargus@marathonhealth.com.au or 
	Fax Dubbo 0268265299 Bathurst 0263 326648

CONSENT
Does the client consent to this referral and the sharing of their health information between health professionals for the purpose of this referral?
YES  / NO  (delete yes or no as relevant)

Date of referral:<TodaysDate>

Referring Doctor 
<DrDetails>
<DrProviderNo>
   
<PracticeLetterhead>

Patient Details
Name: <PtFullName>
DOB:<PtDoB>    Age: <PtAge>    Gender:<PtSex>
Address: <PtAddress>
Ph.(home):<PtPhoneH>    Ph. (mob):<PtPhoneMob>   Ph. (work):<PtPhoneWk> 
Email:<PtEmail>
Ethnicity:<PtEthnicity>      <SmkStatus>
Medicare no. <PtMCNo> <PtMCLine>   exp.<PtMCExpiry>
Pension card no.<PtPensionNo>
DVA card no. <PtDVANo> <PtDVACard>
PCEHR: <PtIHI>

Emergency Contact Information
Name: <NOKName>             Relationship:<NOKRelation>
Phone no. <NOKContact>     Alt. phone no. <NOKContact2>
  
Reason for referral

Past History
<SelectedPMH>

Medications
<CurrentRx>

Measurements
<Observations>

Investigations
Please attach the most recent pathology results including HbA1c, biochemistry, cholesterol (total/HDL/LDL/tg), urinary microalbumin.
<Ix>

Is this referral part of a Team Care Arrangement?
If so, please attach a copy of the Team Care Arrangement (TCA) and the Enhanced Primary Care (EPC) referral.

Additional Information
Please provide any other additional information that maybe relevant for the referral

Please return completed referral via argus ahargus@marathonhealth.com.au or 
fax Dubbo 0268265299 Bathurst 0263326648