Asthma Australia - Referral Service

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

The Asthma Australia Referral Service is available for patients aged over three years.

The COACH Program® is available for patients aged 12 years and older with a confirmed asthma diagnosis
 
Date of Referral: <<Miscellaneous:Date (short)>>

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:Sex>>
Aboriginal or Torres Strait Islander decent?: <<Patient Demographics:ATSI>>
Country of birth: <<Patient Demographics:Country of Birth>>
Cultural Background: <<Patient Demographics:Ethnicity>>
Main language spoken at home:<<Patient Demographics:Language Spoken>>
	Asthma Australia to contact:<<Who are Asthma Australia to contact>>
	Name:
	Phone:
	Email:
Interpreter required: <<Interpreter required?>>
Language required: <<Language required>>

Reason for referral:
<<Reason for referral >>

Current Medications:<<Clinical Details:Medication List>>

Referrer Details: 
Name of Doctor: <<Doctor:Name>>
Practice: <<Practice:Name>>
Address/Post code:<<Practice:Address>>  
Telephone: <<Practice:Phone>>
Fax:  <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Receive copy of Asthma Australia patient correspondence: <<Receive copy of Asth.Aus patient correspondence>>

Signed electronically: <<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.