Armajun AHS

Armajun Referral Form

Contact your Telecare Coordinators if you need assistance with this form:
kids@telecare.com.au
Phone: 03-9933-4633

Coordinator Name *

Enter your name: *

Role *

Patient First Name: *

Patient Last Name: *

Patient Date of Birth: *

Medicare Card *

Medicare IRN *

Medicare Expiry

Primary Guardian NAME

Primary Guardian PHONE

Reason for Consult (more than one can be selected)

Other

Upload Referral *

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Upload Drug/Medication Chart

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Upload Recent Vitals Measurements (Height (cm), Weight (kg), Blood pressure, Heart Rate (bpm)

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Upload Medical History

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E.g Hospital discharge summaries

Upload other clinical document(s)

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Previous geriatrics letters if any; previous brain scans if any (CT, MRI or PET)

Upload other relevant documents

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Comments (OPTIONAL)