Notification Patient Registration Form Oct10 Final by 5IQG64GM

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									                                           AUSTIN AGED CARE FAST TRACK X-RAY
                                       NOTIFICATION AND PATIENT REGISTRATION FORM
                                                 AUSTIN PHONE: 9496 4898           FAX: 9496 3572

                          Aged Care Home Staff Member to Complete & Fax to Austin on 9496 3572
                          prior to resident being transported to Austin Aged Care Fast Track X-ray
                                                      Original form to accompany resident
                       Date
                       UR number (if known)
                       Surname
                       Given Names
                       Date of Birth
                       Sex
    Patient Details




                       Country of Birth
                       Marital Status
                       Religion
                       Medicare Number
                       "Person on Card" Reference Number
                       Expiry date
                       Private Health Insurer
                       Fund Number and Schedule
                       Pension Number
                       Next of Kin
 Next of Kin
   Details




                       Address
                       Telephone
                       Relationship to patient
                       Aged Care Facility Name
Aged Care
 Home's
 Details




                       Address
                       Telephone and FAX Number

                       Level of Care available (Pls Circle)       High Care / Low care

                       Local Medical Officer (GP) Name
 Details
  GP




                       Address
                       Telephone and FAX Number
                       Is this an Injury?
    Clinical Details




                       How did the Injury occur?

                       Type of X-ray required?
                       Can resident be managed at facility if
                       X-ray showns significant clinical
                       finding e.g fracture, chest infection?
                       Form Completed by:
 Notif.
  by




                       Name and Designation of RACF
                       staff member
                                                     Hospital use only below this line
                       Radiology Interim Report
    Radiology




                       Name of Radiologist / Registrar
                                                                Resident returned to aged care home
                       Action (Indicate in relevant box)        Resident admitted to ED
                                                                Other (Specify)

                         This completed Form MUST accompany the Patient after X-ray




                                                                                                      Revised Oct 2010

								
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