PROFORMA FOR EPiPC EMAIL SUPPORT (FAX TO (02) 69339268)

Patient details*

Patient name	<<Patient Demographics:First Name>>	
DOB	<<Patient Demographics:DOB>>	
Medicare number	<<Patient Demographics:Medicare Number>>	
Primary carer name:		Primary carer DOB:		
Address	<<Patient Demographics:Address>>	
Contact mobile	<<Patient Demographics:Phone (Mobile)>>	Email	<<Patient Demographics:E-mail>>	

Demographic details:

	Aboriginal and/or Torres Strait Islander 		Refugee or Asylum Seeker	
	Culturally And Linguistically Diverse (CALD)        		Interpreter required? 
(language_______________________)	
	Out Of Home Care (OOHC)		DCJ/ support service involved	

Reason for referral*

	Early childhood developmental query		
	Early childhood behavioural query	
	Both early childhood developmental and behavioural query		

If developmental concern, please indicate which domain(s) is affected:
	
	Speech & language 		Fine motor	
	Gross motor		Personal/social	
	Global			

Preferred format*

	Email support	
					
Specific referral question(s) for Community Paediatrician to address*

	

Short summary of child’s medical history relevant to referral query* 

	

Services currently involved:

	Speech pathology		Occupational Therapy	
	Psychology/ counselling/ school counsellor		Physiotherapy	
	Dietitian			Other	

Further details of services involved

	

Referrer details*

Name	<<Addressee:Name>>
	
Practice location	<<Addressee:Address>>
	
Preferred contact details for correspondence 
(e.g. email/fax)		
Signature	
	Date	<<Miscellaneous:Date (short)>>	
If GP registrar, name and contact details of GP supervisor		GP supervisor co-sign