Who can be referred
Patients living in Western Australia with asthma and/or COPD. All services are fully bulk billed.

How to refer
Referrals must come from a GP or other healthcare professional. We do not accept self-referrals.

What to include
Please fill out ALL sections of the referral form and attach relevant documents, including the patient's Asthma/COPD Action Plan and Patient Management Plan.

Important: this is not an emergency service
•	Medical emergency: call 000 or go to your nearest emergency department.
•	Urgent but not an emergency: contact your GP or call Healthdirect on 1800 022 222 (available 24/7).

Referral From	
Name:		
Provider Number:		
Phone:		
Address:		
Fax:		

Secure Messaging	Healthlink address ID: waasthma
	
Fax	(08) 9289 3601	
Post	Respiratory Care WA
36 Ord Street
West Perth, WA 6005	
Patient Details	
First name(s):		
Family name:		
Preferred name:		
Title:		
Date of birth:		
Gender:		

Address incl. 
Street, City, State.		
Mailing Address 
(if different):		
Post code:		Email:		
Telephone No:	
Home Phone:		Work Phone:	
	
Mobile:		Fax:		

Special Needs:	
Is an interpreter required?		If yes, language/dialect:		
Other special needs:	

Medicare eligible:			
Medicare number:		Ref:		Expiry:		

Next of Kin/Guardian 	
Full name:		
Relationship:			
Phone:		

Patient is aware we will contact them to confirm appointment via email/SMS information provided on the referral.

   Consent for email confirmation of appt times
   Consent for SMS confirmation of appt times
   Consent for both email/SMS confirmation of appt times

Referral Details	
Is the referrer the usual GP for the patient?		
If no, name of usual GP:		
Contact number:		
Length of referral:		
Is this a renewed referral?                    		

Reason for referring:		
Adult Respiratory Hub (Includes lung function testing, Registered Nurse assessment/education)

Children’s Respiratory Hub (Includes lung function testing, Registered Nurse assessment/education, Specialist Review if necessary)	
	
Diagnosis: 	Suspected asthma   	Confirmed asthma 	
	Suspected COPD 	Confirmed COPD 
	Undiagnosed / Other

Chronic Condition Management Plan (CCMP) Initiated -  YES    NO   Unsure   N/A

If yes, has the CCMP been updated in the last 3 months? -  YES    NO   Unsure  

Asthma / COPD Action Plan initiated -  YES     NO   Unsure   N/A

If yes, has Action Plan been updated in the last 3 months? -   YES     NO   Unsure  

** Any recommendations for CCMP or Action Plan updates by a Respiratory Care WA Health Professional will be provided in the report for GP to review with the patient. **Respiratory Care WA does not Medicare bill for this activity.

Clinical Information	
Observations:	 
	
Percentile, height & weight:		
Current problem:		
Past history:	 	
Current medications:		
Allergies:	 	
Other clinical information:	 
	
Family history:	
	
Social history:	

Additional Clinical Information	

Has your patient utilised emergency / urgent care resources in the past 12 months?   YES   NO  
If yes:

  1-2
  3-5
  5+ 

Has your patient required antibiotics for treatment of respiratory complications in the past 12 months?   YES   NO
If yes:

  1-2
  3-5
  5+ 

Has your patient required oral corticosteroids for treatment of their respiratory condition in the past 12 months?   YES   NO
If yes:

  1-2
  3-5
  5+ 

Other relevant Clinical Information