Asthma Australia - Patient Education Referral Service

Secure electronic transfer to: FA40060001U or fax through to: 07 3257 1080

This service is available for patients aged 3 years and older with a confirmed asthma diagnosis  

Date of Referral: 

RE: Patient Demographics.Full Name
DOB: Patient Demographics.DOB
Address: Patient Demographics.Address
Telephone: Patient Demographics.Phone (Home)			
Mobile: Patient Demographics.Phone (Mobile)
Gender: Patient Demographics.Gender

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

Signed electronically: Treating Doctor.Name

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

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