Full Patient Name
*
DOB
*
Patient Street Address
*
Patient Suburb & Postcode
*
Patient Phone
*
Medical History
*
Medications
*
Reason for Wound Referral
*
Wound Care Regime - Previous or Current
*
Nutritional Supplements Being Used
For Pressure Injuries, Equipment Currently in Place
Pressure Injury Prevention & Continence Management Strategies in Place
For Lower Limb Vascularisation, is a Vascular Specialist involved?
*
Yes
No
Name and Contact Details
*
Has the Patient Been Reviewed by a Vascular Specialist in the Last 6 Months?
*
Yes
No
Please Provide Report / Outcome
*
Please provide the following
Wound Photography
Recent Wound Swab
Recent Pathology Results
Recent Antibiotic Treatment
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Is GP involved with wound management?
*
Yes
No
Does GP want to be involved in case conferencing?
*
Yes
No
Are telehealth facilities available?
*
Yes
No
Clinical Details
*
Referring Doctor
*
Practice Address
*
Email Address
*
Will receive a copy of this referral along with future correspondence
Provider Number
*
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Referral Date
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