REFERRAL FORM
GCPHN Persistent Pain Program

Phone Joyce McSwan for further information on: 0412 327 795
Forward completed referral via Medical Objects (preferred) to:
	Name: Joyce McSwan
	Organisation: TPIG Persistent Pain Program
	Provider Number: JM4226000Q0
or Fax: 07 3539 9801

DATE: <<Miscellaneous:Date (short)>>
PATIENT DETAILS 

RE:  <<Patient Demographics:Full Name>>	DOB: <<Patient Demographics:DOB>>	Gender: <<Patient Demographics:Gender>>	
Address:  <<Patient Demographics:Full Address>>	Email: <<Patient Demographics:E-mail>>	
Home Phone:  <<Patient Demographics:Phone (Home)>>	Work Phone: <<Patient Demographics:Phone (Work)>>	Mobile Phone: <<Patient Demographics:Phone (Mobile)>>	

PATIENT PRESENTATION

  <<Patient presentation>>

PAST HISTORY

Has the patient previously visited a pain clinic or participated in a pain management program?    <<Has pt previously visited a pain clinic or pain mgt>>
If yes, specify where and when: <<If yes, specify where and when>>

Clinical History:  <<Clinical Details:History List>>

Investigations:  <<Summary:Investigation Results (Selected)>>

Medications: <<Clinical Details:Medication List>>

Allergies:  <<Clinical Details:Allergies/Adverse Reactions>>

Smoking:  <<Clinical Details:Smoking>>

Alcohol:  <<Clinical Details:Alcohol>>
	
Patient must meet ALL the following criteria to be eligible for the program:

•	The patient has persisting pain which has lasted for more than 3-6 months 
•	The patient is not suitable for surgical or urgent pain specialist interventions 
•	The patient is not a palliative care patient
•	The patient requires improved self-management strategies and skills to optimise ongoing care
•	The patient is able to participate in group education
•	Able to give voluntary, informed consent for the ongoing collection of audit data.

<<Patient meets ALL criteria listed in referral>>	REFERRING GP/ORGANISATION DETAILS 
GP's Name: <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

REFERRING ALLIED HEALTH PROFESSIONAL DETAILS (if this applies) **A GP Sign off is mandatory for this referral to be accepted**
AHP's name:  
Allied Health Profession:  
Organisation:  
Phone:   
Fax:   
Email:   

On the receipt of this referral, the patient will be contacted with details of the Gold Coast Primary Health Network’s Persistent Pain Program to be reviewed with an initial service assessment.  Our Service Assessments will be held at our office at The Atrium, Varsity Lakes.  The Pain Education Program will be held at various north and south community centres on the Gold Coast.  Patients will be able to choose from a selection of dates to suit their individual needs.  Please provide for your patient the included “Patient Information Sheet” for their further information.  Patients can also call us directly to enquire further on: 0412 327 795 

The Persistent Pain Program is supported by funding from Gold Coast Primary Health Network through the Australian Government's PHN Program. GCPHN is collecting your personal information for the purpose of assisting its activities and functions in the primary health care sector. Your contact details may be used to forward information and notifications from GCPHN. In some circumstances we may provide your information to our funding agency (Dept of Health) or to service providers that enter into legal contracts with us which are bound by confidentiality.  There is no legal requirement for you to provide your personal information, however if you chose not to disclose your personal information this may exclude you from our services and programs. We do not routinely disclose information overseas. For further information on how we manage your personal information see our website  https://gcphn.org.au/privacy-policy/