Patient Services
Chris O’Brien Lifehouse
PO Box M33
Missenden Road
NSW 2050
Email: clinics@lh.org.au
Fax: +61 2 9383 1000
Ph: +61 2 8514 000

Referral to Lifehouse
Patient Details
Surname	<PtSurname>	
Given Names	<PtFirstName>, <PtMidName>	
Gender	<PtSex>	
Date of Birth	<PtDoB>	
Address	<PtAddress>
	
Contact Phone Number	Home:<PtPhoneH>	Work:<PtPhoneWk>	Mobile:<PtPhoneMob>	

Referral Details
Lifehouse Clinician Name		
Period of Referral	3 months/12 Months/Indefinite	
Interpreter Required	YES/NO
Language:	
Reason for Referral	
	
Relevant Past Medical History	
	
Medications	Medications List attached: YES/NO
<CurrentRx>
	
Allergies	<Reactions>
	
Investigations / Test Results included	Pathology: YES/NO
Histopathology: YES/NO	Radiology: YES/NO
Other:	
Additional Information		

Referrer’s Name: <DrDetails>			Contact Number: <DrPhone>
Provider Number: <DrProviderNo>		Date: <TodaysDate>