MARATHON HEALTH PRIMARY HEALTH SERVICES CHRONIC DISEASE TEAM – REFERRAL
	Please return completed referral via argus ahargus@marathonhealth.com.au   

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:<<Miscellaneous:Date>>

Referring Doctor 
<<Doctor:Name>>
<<Doctor:Provider Number>>
<<Miscellaneous:Practice Letterhead>>
   
Patient Details
Name: <<Patient Demographics:Full Name>>
DOB:<<Patient Demographics:DOB>>  Age:<<Patient Demographics:Age>>  Gender:<<Patient Demographics:Sex>>  
Address: <<Patient Demographics:Full Address>>
Ph.(home):<<Patient Demographics:Phone (Home)>>  Ph. (mob):<<Patient Demographics:Phone (Mobile)>> Ph. (work): <<Patient Demographics:Phone (Work)>>
Email: <<Patient Demographics:E-mail>>
Ethnicity: <<Patient Demographics:Ethnicity>>     <<Clinical Details:Smoking>>
Medicare no. <<Patient Demographics:Medicare Number>>    exp.<<Patient Demographics:Medicare Expiry Date>>
Pension card no.<<Patient Demographics:Pension Number>>
DVA card no. <<Patient Demographics:DVA Number>>
PCEHR: <<Patient Demographics:IHI>>

Emergency Contact Information
Name: <<Head of Family:Full Details>>

Reason for referral

Past History
<<Clinical Details:History List>>

Medications
<<Clinical Details:Medication List>>

Measurements
Height	<<Clinical Details:Measurements>>	BP	<<Clinical Details:Measurements>>	
Weight	<<Clinical Details:Measurements>>	BSL	<<Clinical Details:Measurements>>	
Waist	<<Clinical Details:Measurements>>			
BMI	<<Clinical Details:Measurements>>			

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

<<Summary:Investigation Results (Selected)>>

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