SES010413 U0 BINDING MARGIN - NO WRITING Health FAMILY NAME NSW | SeShssarbetna” nen nae Cue rame Facility: pos )__i_|wo AODRESS REFERRAL - AMBULATORY CARE UNIT _| tocstion/waro COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE Prot Peter Smerdely CQ OrLovise Baird Or Sarah Baldwin Q1Dr Kannie Chuang Cl Dr Chris Dedousis Dr Litsa Mortis Dr Grant Pickard O Dr Tony Youssef O1Dr Yun Xu Patient Family Name: Bivens a pop; MALE FEMALE: (please circle) Address: Phone Number: _ Mobile No: E medicare wo: JE) JIL LLL soaicare expiry bate: ‘Note: - include patient's reference number as the eleventh number of the Medicare card. Interpreter Required: Yes / No Dialect: _ Reason for referral: Diagnosis/Medical History: If medication required please complete the Community Medication and Authorisation Record Please tick if patient arriving by ambulance. | Referral Dr.________ Contact No / Page No: —___ ‘SIGNATURE: DATE: Referring Or Provider No. LINN AYVS ANOLV ING - TwaYNssay Telephone Address Please complete this section in full or with practice stamp Practice Stamp Fax completed form: 9113 1923, eLvOLlosas NO WRITING Page 1 of 1AA FOR MEDICAL RECORD USE ONLY + MEDICAL RECORD COPY + South Eastern Sydney Illawarra Area Health Service COMMUNITY MEDICATION AUTHORISATION & RECORD OTHER NAMES DOB SEX MRN BAR CODE ‘AFFIX PATIENT IDENTIFICATION LABEL HERE ‘Original MUST be sent home with patient ‘1st Presoriber to Print Patient Name & Check Label Correct: ALLERGIES & ADVERSE DRUG REACTIONS (ADA) Oi known Dlunknown Drug (or other) Reaction / Type / Date Initials Drug (or other) Reaction /Type/Date _| initials In the event of an anaj 0.3 mg - 0.6mg (0.3ml. - 0.5mL) by Intramuscular injection as per local hospital policy reaction administer adrenaline 1:1000 ‘Medication (Print Generic Name) ‘Medication (Print Generic Name) Dose Fluid (Vv Only) Dose Faia @v Only) Route Volume (V Only) Route Volume (IV Oniy) Frequency Rate (WV Only) Frequency Rate (WV Only) Indication ‘Special Instructions ‘Completion Date ‘Special instructions ‘Completion Date MO Signature Date Ordered MO Signature Date Ordered MO Name (Print MO Contact No. WO Name (Print NO Contact No. Date Time Date Time. RN Signature Soies 02/2008 ALUM LON OG ~ NOW ONION