Patient Referral

Refer a patient for WorkCover injury care

Refer a Patient

Please complete this form to refer a patient for WorkCover injury care. All information is confidential and will be used to coordinate treatment.

Referring Practitioner Information

Practitioner Name *

Practice Name *

Email Address *

Phone Number *

Patient Information

First Name *

Last Name *

Date of Birth *

Patient Contact Information

Email Address *

Phone Number *

Emergency Contact

Home Address *

WorkCover Information

WorkCover Claim Number

Employer *

Date of Injury *

Brief Description of Injury *

Recent Imaging

Anatomical Area Imaged

Imaging Type

X-ray Ultrasound (US) MRI CT Bone Scan

Imaging Provider

SKG Apex PRC I-Med Western Radiology Capital Radiology Envision Q-Scan

Investigations

Blood Tests / Pathology

FBE (Full Blood Exam) UEC (Urea & Electrolytes) CRP (C-Reactive Protein) ESR (Erythrocyte Sedimentation Rate)

Past Medical History

Regular GP and address

Hypertension Diabetes (Type 1/2) Heart Disease Stroke / TIA Asthma / COPD Kidney Disease Liver Disease Cancer (past/ongoing) Bleeding/Clotting Disorder Thyroid Disease Osteoporosis Depression / Anxiety Chronic Pain Current or Past Smoker None of the above

Other Conditions

Additional Information

Current Treatment or Medications

Additional Notes / Clinical Summary

I confirm that I have obtained appropriate consent from the patient to share this information with Premier Health Australia for the purpose of coordinating healthcare services. I understand that this information will be treated confidentially in accordance with healthcare privacy regulations.

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Address: 149 Walcott St, Mount Lawley WA

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