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	<<Patient Demographics:Surname>>	
Given Names	<<Patient Demographics:First Name>>, <<Patient Demographics:Middle Name>>	
Gender	<<Patient Demographics:Gender>>	
Date of Birth	<<Patient Demographics:DOB>>	
Address	<<Patient Demographics:Address>>
	
Contact Phone Number	Home:<<Patient Demographics:Phone (Home)>>	Work:<<Patient Demographics:Phone (Work)>>	Mobile:<<Patient Demographics:Phone (Mobile)>>	

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
<<Clinical Details:Medication List>>
	
Allergies	<<Clinical Details:Allergies/Adverse Reactions>>
	
Investigations / Test Results included	Pathology: YES/NO
Histopathology: YES/NO	Radiology: YES/NO
Other:	
Additional Information		

Referrer’s Name: <<Doctor:Name>>			Contact Number: <<Doctor:Phone>>
Provider Number: <<Doctor:Provider Number>>	Date: <<Miscellaneous:Date>>