Referrers Details:
Date: <TodaysDate>		
GP Name: <DrName>				GP Provider Number: <DrProviderNo>	
GP Practice: <Practice>	
Phone: <UsrPhone>				Fax:<UsrFax>	
Postal Address: <UsrAddress>	

Patient Information:
Name:	<PtFullName>		DOB:  <PtDoB> (<PtAge>)	
Phone:	<PtPhoneMob>		Email:	<PtEmail>	
Postal Address: <PtAddress>	
Best contact: <Preferred method of contact?>	Permission to leave a message?  <Permission to leave a message?>	

Please note the following are exclusion criteria: 
•	Patients undergoing active treatment for cancer, infection or fractures:  <--Is the patient Patients undergoing active treatment for cancer, infection or fractures?>
•	Patients receiving high dose opioids (>60mg morphine equivalent per day):  <Is the patient receiving high dose opioids (>60mg morphine equivalent per day)?>
•	Workers compensation, third party, and motor accident injury claims:  <Does the patient have am actove workers compensation, third party, and motor accident injury claim?>
Patient Pain History:
<Patient pain history>
Patient Medical History:
<SelectedPMH>
Medication:
<SelectedRx>
Allergies:
<Reactions>
Immunisations:
<Imm>
Please return this form to the Chronic Pain Management Program Facilitator in your area, details are available on the ACT&Southern NSW HeathPathways portal here.