Referral Form – NBS Health Services

NBS Health Referral Form
Phone: 0468631399
Email: info@nbshealth.com.au

NBS Health always sends a receipt of referral correspondence. If you don't receive this, please call to check if we have the referral.

1. Referrer and Hospital Details

Referrer (Please tell us about you)

First Name

Last Name

Email (Additional)

Role title

Hospital Name

Hospital Number

Work number

2. Specialist Details

First Name

Last Name

Phone

3. GP Details

First Name

Last Name

Phone

4. Patient Details

Please enter the patients details

First Name

Last Name

Date of birth

Sex(Required)

Female

Male

Other/unspecified

Phone

Address for discharge (No PO Boxes)

Cultural / religious / language considerations (optional)

Name of health fund

Membership number

5. Next of Kin

First Name

Last Name

Relationship

Phone number

6. Patient's Medical Details

Admission date

PMHx

Proposed DC date

Any known infections?(Required)

Yes

Primary diagnosis and interventions / surgical procedures (if applicable)

Details

Any known allergies?(Required)

Yes

Details

7. Service Requirement Details

Details

Service Start Date

List of Services Required

Additional Information

8. Authorisation

Please Check(Required)

Hospital treating doctor/surgeon declares that the patient is medically stable, and is not being discharged against medical or allied health advice. The patient has consented to NBS Health Services disclosing their personal information to the health fund to ascertain funding eligibility, confirm

I will send the patient home with 3 days of consumables for all Hospital Care at Home referrals.

Referrer name

Role title

Date

Signature

Declaration(Required)

I declare that the information provided by me in the referral is true and correct.

9. Referral Checklists

Please provide the following documents (attach to email to info@nbshealth.com.au)

I have included a wound care chart (if applicable)

I have included a medication and PICC chart (if applicable)

NBS Referral Form

1. Referrer and Hospital Details

Referrer (Please tell us about you)

2. Specialist Details

3. GP Details

4. Patient Details

Please enter the patients details

5. Next of Kin

6. Patient's Medical Details

7. Service Requirement Details

8. Authorisation

9. Referral Checklists