GP Referral Form | Respiratory Care WA

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Referral Form - Adult or Children's Respiratory Hub

Any patients living in Western Australia with asthma and/or COPD can be referred to our fully bulk billed services. Telehealth appointments are available for remote and regional patients. Please complete all sections and attach all relevant patient documents including Asthma/COPD Action Plan and Patient Management Plan. Please send to us via Healthlink ID: waasthma, email to [email protected] or fax (08) 9289 3601.

"*" indicates required fields

Step 1 of 3

33%

Patient Details

Adult Respiratory Hub

Education

Lung Function Testing and Education

Respiratory Specialist Review (GP Referral Only)

Children's Respiratory Hub

Education

Lung Function Testing and Education

Respiratory Specialist Review (GP Referral Only)

Diagnosis*

Asthma

COPD

Asthma and COPD

Undiagnosed/other

First Name*

Last Name*

Date of Birth*

DD slash MM slash YYYY

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Male

Female

Other

Phone*

Email*

Identifies as Aboriginal or Torres Strait Islander?*

Aboriginal

Torres Strait Islander

Both

Not Aboriginal or Torres Strait Islander

Interpreter Required?*

No

Yes

If yes, please specify language spoken:*

Medicare Card Number*

Medicare Reference Number*

Medicare Card Expiry Date*

DD slash MM slash YYYY

Carer Details

Complete as necessary or skip to next page if not applicable.

First Name

Last Name

Relationship to patient

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Is shared care arrangement in place for minor?

Yes

No

Is the Carer the primary contact for the patient's appointments?

Yes

No

Referrer Details

First Name*

Last Name*

Position Title

GP / Medical Practitioner

Nurse

Allied Health Professional

Other

Provider Number*

Please Specify*

Referrer Organisation*

Referrer Phone Number*

Fax

Email*

Diagnosis / Clinical Details:*

Please give us much detail as possible.

Asthma or COPD Action Management Plan

Drop files here or

Max. file size: 256 MB.

Date of Referral*

DD slash MM slash YYYY

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Email(Required)

36 Ord Street, West Perth, WA 6005

[email protected]

Monday to Friday: 8:30am to 4:30pm (excl. public holidays)

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Respiratory Care WA acknowledges the Traditional Owners and Custodians of Country throughout Australia and their continuing connection to land, waters and community. We pay our respect to them and their cultures, and Elders past, present and emerging.

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