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Rehabilitation Referral Form

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Rehabilitation Referral Form

If you're a GP who wants to refer a patient to MacRehab, or you want to do a self-referral, go ahead and fill out this simple e-form and press submit or download the PDF version HERE and send via fax. Once the form is sumbitted, we'll be in touch with patients for next steps.

* required field

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MacRehab Hospital*

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Admission request*
- Inpatient Admission Request
- Day Only Admission Request
Date of request for admission*
MM slash DD slash YYYY
Referral completed by*
Designation*
Private room request
- Yes
- No
Name*
DOB*
MM slash DD slash YYYY
Hidden
Age
Gender*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Telephone*
Next of kin*
Relationship
Telephone*
Health fund
Veteran Affairs Nº
Colour of DVA card
Medicare Nº
Expiry date
MM slash DD slash YYYY
Pension Nº
Rehab spec
Programme

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Has this patient had previous admissions to this hospital?
- Yes
- No
Referring doctor*
Telephone*
Usual GP
Phone
Attending doctor
Phone
Attending doctor notified of pre-admission
- Yes
- No
Attending doctor to be phoned when patient arrives
- Yes
- No
Transferring from other hospital
- Yes
- No
Hospital name
Ward name
Phone
Admission date from hospital transferring
MM slash DD slash YYYY
Diagnosis*
Past medical history

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Known infections
- HEP
- ESBL
- VRE
- MRPA
- N/A
Weight
Gastro symptoms in ward last 96 hrs
- Yes
- No
MRSA status
Swabs taken
- Yes
- No
Date Swabs taken
MM slash DD slash YYYY
Results
- Nose
- Groin
- Wound
- Axillae
Estimated length of stay
Home situation
Mobility status
Discharge plan
Continence/IDC
Wound/Drain
Mini mental cognitive status
Is this admission the result of:
A fall in the community
- Yes
- No
MVA/workplace accident/insurance claim
- Yes
- No
Insurer name
Case manager contact
Claim #
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Name
This field is for validation purposes and should be left unchanged.

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