New Patient Referral for Dr Meena Mittal - Persistent Pain Solutions

Date of Referral

Priority Status

Patient Status

Patient Details

Title

First Name

Surame

Date of Birth

Gender

Residential Address

Suburb

State

Post Code

Home Phone

Work Phone

Mobile Phone

Email Address

Interpreter Required

Interpreter Language

Medicare Number

Private Health Fund Number

Worker’s Compensation Claim Number

TAC/ MAIB Claim Number

DVA Number

Details of Referring Doctor/Allied Health Professional

Name

Specialty

Name of Practice

Address

Phone

Fax

Email Address

Provider Number

Reason for Patient Referral

Other

We kindly request you to provide the following Patient Information in addition to the above (at your convenience):

Past and Current medical history
List of current medications
List of allergies
Social and Work History
Investigation results: Pathology, Radiology, Other
Correspondence from other healthcare providers in relation to current pain problem
Approval letter if Worker’s compensation/ TAC/ Third party Insurer

These can be emailed to [email protected] or faxed to (03) 9012 4123.

Please note that patients under Worker’s compensation, TAC, third party insurers will require a valid approval before an appointment is offered.

We shall provide confirmation of receipt of referral within 48 hours of receiving this form. The patient shall be contacted during this period to organise an appointment. In the event that we are unable to obtain a patient response, we shall send a notification to your practice informing you of the same.

Please feel free to directly contact Dr Meena Mittal or the staff at Persistent Pain Solutions if you wish to discuss the referral. We will be delighted to assist you and your patient.

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Patient Details

Details of Referring Doctor/Allied Health Professional

Reason for Patient Referral

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