BHS SMART Referral
Referral date: <FormattedDate>
For further information please go to the GP Liaison Website https://gp.bhs.org.au
 	Version 8
(9/2017)	

REFERRED BY
Name: <DrName>
Practice: <Practice>
Address: <UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Provider #: <DrProviderNo>
HPI-I:<PracticeHPIO>

	PATIENT DETAILS
Name: <PtFullName>
Gender: <PtSex>
DOB: <PtDoB>
Address: <PtAddress>
Home ph: <PtPhoneH>
Mobile: <PtPhoneMob>
Email:<PtEmail>
IHI:<PtIHI>
Medicare #: <PtMCNo>
Medicare expiry: <PtMCExpiry>
Pension:<PtPensionNo>
DVA #: <PtDVANo><PtDVACard>
Health Insurance:<PtInsFund>
ATSI: <PtEthnicity>
Next of kin:<NOKName>
Next of kin telephone:<NOKContact>
Interpreter required: <Interpreter required?>	
SPECIALTY SERVICE REQUIRED - THIS SECTION MUST BE COMPLETED
<Specialist - MANDATORY>
		
REFERRAL DETAILS
GP Advised Priority: <GP Advised Priority>
Previous referral for same condition: <Previous referral for same condition?>
Reasons for repeat referral: <If yes to above, reasons for repeat referral>
Are you the patient's usual GP: <Are you the patient's usual GP?>
If not, name of usual GP:<If not, provide name of Usual GP & Practice>
	SPECIAL ALERTS
Cancer status: <Cancer status for triage>
National Bowel Cancer Screening referral: <Is this for positive FOB for NBS?>
NBS reference number: <If yes, National Bowel Screening reference #>
Smoking status: <SmkStatus>
Antenatal Shared Maternity Care:<Is patient for Antenatal Shared Maternity Care>	
PATIENT CONSENT
Patient consents to attend MBS bulk billed clinic if available: <Patient consents to MBS bulk billed clinic if avail?>
If yes, do you wish this to be an indefinite referral? <If yes, do you wish this to be an indefinite referral?>
Patient consents to sharing medical information: <Patient consents to sharing of medical information>
	
PROVISIONAL DIAGNOSIS
<Provisional diagnosis>
	ALLERGIES
<Reactions>	
OBSERVATIONS (If clinically relevant)
BP (if clinically relevant): <Current blood pressure (if clinically relevant)>
WEIGHT (if clinically relevant): <Current weight (if clinically relevant)>
BMI if >30 (req for endoscopy patients): <BMI if >30 (req for endoscopy patients)>
	
DETAILED HISTORY OF PRESENTING COMPLAINT
<Detailed history of presenting complaint>	
RELEVANT PAST MEDICAL AND SURGICAL HISTORY
<PMHAll>	
PSYCHOSOCIAL HISTORY
<SocialHx>	
REFERRALS TO OTHER SERVICES
<Referrals to other services eg; allied health (include date)>	
MEDICATION (please ensure this is accurate)
<CurrentRx>	
HAVE ANY INVESTIGATIONS BEEN ORDERED TODAY?
<Did you order any investigations today?>	
TESTS ORDERED TODAY
<List any tests ordered today>	
NAME OF PROVIDER
<Name of provider (ie;Dorevitch, BHS Radiology)>	
HAVE TESTS ORDERED AT TIME OF REFERRAL BEEN COPIED TO BHS OUTPATIENTS?
<Tests ordered today copied to BHS Outpatients>	
RELEVANT RESULTS AND INVESTIGATIONS
<Ix>
Please include any reports that will assist with patient management

GP signature: ________________________________________________________________________