Ramsay Clinic New Farm
Patient Referral
Email to referrals.nfc@ramsayhealth.com.au or Fax to (07) 3254 9601

Patient Details:

Patient’s Name:  <<Patient Demographics:Full Name>>   DOB: <<Patient Demographics:DOB>>
Contact Number:  Home Phone:    <<Patient Demographics:Phone (Home)>>   Mobile Phone: <<Patient Demographics:Phone (Mobile)>>
Address: <<Patient Demographics:Address>>
DOB <<Patient Demographics:DOB>>

Referral Type

General Referral: <<General Referral? Y/N>>
<<Referral Type? >>                                                                          <<Inpatient or Outpatient?>>

EDP Admission – Referrals to be addressed to Dr Warren Ward, Dr Rhys Thomas, Dr Hannah Galloway or Dr David DeLuchi
Addictions Admission - Referrals to be addressed to Dr Wole Akosile 
<<EDP Admission: Doctor Name>>
(Accepted referrals will be followed up with an appointment for assessment prior to a decision regarding admission/ management)

<<Addictions Referral? >>

Admission- Patient information required:

•	Situation – Presenting issue, current mental state/ symptoms and risk status – mainly suicidal ideation/past attempts, deliberate self-harm and aggression)
•	Current community supports – private psychiatrist, psychologist, and dietician or case management.
•	Current Medications
•	Substance use – including ETOH.
•	Previous/Current MH diagnosis
•	Chronic medical conditions/ mobility issues
Clinical Notes: 
<<Admission Clinical Notes>>

EDP Additional Clinical Notes/Medical History:

Amenorrhea:  <<Amenorrhoea>>
Physical complications, Medications, Mental Health assessment, Suicidal ideation, DSH, Current/previous community support/admissions: <Physical complications, Medications, Mental Health assessment, Suicidal ideation, DSH, Current/previous community support/admissions:>
Blood Results (less than 2wks old- ELFT; Mg; & FBC: (see attached).
Postural observations: 
BP lying:   <<Bp lying>>                                               BP standing: <<BP standing>>
HR lying:   <<HR lying>>                                              HR standing: <<HR standing>>
Routine observations- <<Routine Obs: RR, Temp, Height, Weight, BMI:>>

Referring Doctor Details: (or stamp)

Name:   <<Doctor:Name>>                                             Provider Number: <<Doctor:Provider Number>> 
Phone number:   <<Doctor:Phone>>                              Fax number: <<Doctor:Fax>>
Date:     <<Miscellaneous:Date>>                                   Email:   <<Doctor:E-mail>>
Signature:

Electronic Referrals can be sent via Medical Objects to provider number: RN4005000JY
Please email, fax or call for referral:
 referrals.nfc@ramsayhealth.com.au or Fax: (07) 3254 9601| GP Priority Phone: (07) 3254 9688
People caring for people
ramsaymentalhealth.com.au

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