Asthma Australia - Referral Service

Secure electronic transfer to: HealthLink (asthmaus) or Fax to: 07 3257 1080 or Web via: asthma.org.au/referrals 

Keep your asthma patients on track between visits with our free asthma support.
You can refer your asthma patients over three years old to Asthma Australia.

Date of Referral: Miscellaneous.Date

RE: Patient Demographics.Full Name
DOB: Patient Demographics.DOB
Age: Patient Demographics.Age
Address: Patient Demographics.Address
Telephone: Patient Demographics.Phone (Home)	
Mobile: Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Gender: Patient Demographics.Gender
Aboriginal or Torres Strait Islander decent?: Patient Demographics.ATSI Status
Country of birth: 
Cultural Background: 
Main language spoken at home:
	Asthma Australia to contact: Who are Asthma Austr
	Name:
	Phone:
	Email:
Interpreter required: Interpreter required
Language required: Interpreter language

Reason for referral:
Reason for referral

Current Medications:Clinical Details.Medication List

Referrer Details: 
Name of Doctor: Treating Doctor.Name
Practice: Practice.Name
Address/Post code:Practice.Address  
Telephone: Practice.Phone
Fax:  Practice.Fax
Email: Treating Doctor.E-mail
Receive Patient Summary Report: Receive copy of Asth
Patient Summary Report to be sent via: If yes, preferred me
Signed electronically: Treating Doctor.Name

Patient Consent
Consent has been obtained from this patient/carer to provide their contact details to Asthma Australia for provision of free asthma education and support.