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Print Form Peter MacCallum Cancer Centre REFERRAL FORM Sign completed referral forms and fax to (03) 8559 7371 or email to [email protected] Patient details: Referral Date: Last name: Medicare eligible: First name: D.O.B: Yes No Yes No Medicare number: Sex: Appointment requirements: Address: - Interpreter required: If yes, language required: Preferred contact phone number: - Accommodation assistance required: Email address: Yes No Please select the services you wish to refer the patient to: If unsure of which service to refer, please select "All services". All referrals receive multidisciplinary assessment and will be promptly triaged to the most appropriate service (e.g. Breast, Lung) and clinician. ✔ All services - Prof A. Heriot, Prof D. Rischin, A/Prof T. Leong, Prof J. Seymour, Dr P. James Referrals to All services will enable prompt multidisciplinary care if required (recommended) Cancer Surgery (inc skin) - Prof Alexander Heriot Medical Oncology - Prof Danny Rischin Haematology - Prof John Seymour Familial Cancer Centre - Dr Paul James Radiation Oncology - A/Prof Trevor Leong Preferred site (Radiotherapy only) Bendigo Box Hill Moorabbin East Melbourne Sunshine How long is this referral valid? Reason for referral: If requesting a specific clinician, please specify: Indefinite (recommended) 12 months Is this referral for a second opinion? Yes 3 months (Specialists only) No Room for further clinical details available on the second page Relevant investigations/attachments: The tests identified below are to be completed and results fowarded with the referral (tick the relevant boxes) Relevant blood and microbiology results Operation / Scope notes Histopathology report Diagnostic imaging Other: Comments: Referring doctor: Practice name & address: Name: Provider number: Phone No: Please turn page to complete referral Fax No: MANDATORY SIGNATURE: Page 1 of 2 Patient Name: D.O.B: Relevant clinical information: Please include FHx summary for Familial Cancer Centre referrals Past Medical History: Current Medications: Allergies: Page 2 of 2