Download Peter MacCallum Cancer Centre REFERRAL FORM

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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:
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Patient Name:
D.O.B:
Relevant clinical information:
Please include FHx summary for Familial Cancer Centre referrals
Past Medical History:
Current Medications:
Allergies:
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