Online Referral Form
Your name:
*
Practice name:
*
Your Contact Information
Address:
*
EDI:
Phone:
*
Fax:
Email:
*
Who Would You Like To Refer
Surgeons:
Not required
First available
Mr Hamish Love
Mr Bruce Twaddle
Physicians:
Not required
First available
Dr Tony Page
Dr John Molloy
Dr Hamish Reid
Patient Information
Patient name:
*
Date of birth:
*
DD slash MM slash YYYY
Address:
*
Phone:
*
(must be a daytime contact number)
Patient Email:
*
ACC Covered Injury
Is this an ACC covered injury?
*
Yes
No
ACC number:
*
Date of injury:
*
DD slash MM slash YYYY
How Urgent Would You Like This Patient To Be Seen?
Urgency:
*
Urgent (within 1-2 weeks)
Semi-urgent (within 3-6 weeks)
Routinely (greater than 6 weeks)
If "urgent", please indicate the reason(s) why.
If "urgent", please indicate the reason(s) why.
Clinical Problem
Describe problem and area affected:
*
Side of the body:
*
Injury on left side
Injury on right side
Injury on both sides
Presenting Complaint
Duration of problem:
*
Onset of Problem
Onset:
*
Sudden
Gradual
If "sudden", briefly describe the inital event.
If "sudden", briefly describe the inital event.
Presenting symptoms
Symptoms:
Stiffness/loss of motion
Pain
Weakness
Sleep disturbance
Clicking / catching
Instability
Symptoms:
Stiffness/loss of motion
Pain
Sleep disturbance
Clicking / catching
Giving way
Symptoms:
Stiffness/loss of motion
Pain
Swelling
Sleep disturbance
Clicking / catching / locking
Giving way
Instability
If other please specify.
If other please specify.
What is your likely diagnosis?
Likely diagnosis:
Impingement
Rotator cuff tear
AC joint pathology
Frozen shoulder
Instability
Likely diagnosis:
Labral tear / hip impingement
Trochanteric bursitis/abductor pathology
Adductor tear/tendinopathy
Osteoathritis
Snapping hip
Piriformis syndrome
Likely diagnosis:
Meniscal tear
Ligament injury
Chondral or osteochondral injury
Patellar instability
Osteorthritis
If other please specify.
If other please specify.
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