ABN | 40 625 708 669
 FAX | 03 4059 1919
EMAIL | admin@clinicnineteen.com.au
 WEBSITE | clinicnineteen.com.au
SECURE MESSAGING |Healthlink: nineteen	
Delivering telehealth services to long-COVID patients across Australia	

<TodaysDate>

	Provider Details	
Practitioner Name	<DrName>	
Practice	<Practice>	
Practice Address	<UsrAddress>	
Practice Phone	<UsrPhone>	
Practice Fax	<UsrFax>	
Provider Number	<DrProviderNo>	
Correspondence Email	<PracEmail>	
Secure Messaging Address	<Secure Messaging Address - Healthlink preferred>	

	Patient Details	
Title	<PtTitle>	
First Name 	<PtFirstName>	
Preferred Name	<PtPrefName>	
Surname	<PtSurname>	
Date of Birth	<PtDoB>	
Address	<PtStreet>
<PtCity>, <PtPostcode>, <PtState>	
Medicare Card	<PtMCNo>, <PtMCLine>, <PtMCExpiry>	
Concession Card (Y/N)	Yes/No	
Workcover	<PtInsFund> | <PtInsNo>	
Email Address	<PtEmail>	
Mobile Number	<PtPhoneMob> 	

Reason for Referral	
<Reason for Referral>	

COVID-19 History	
<When was your clients last COVID-19 diagnosis, and roughly how long has your patient had long-COVID for?>	

Current Medications	
<SelectedRx>	

Allergies and Reactions	
<Reactions>	

COVID-19 Vaccination Status	
Number of doses: <How many COVID-19 vaccinations?>  
Brand of vaccine: <Which brands of COVID-19 vaccination?>	

Relevant Past History	
<FamilyHx>
<SocialHx>
<SelectedPMH>	

Referral valid for <Referral length>

Kind regards,

<DrName>
<DrProviderNo>

Please attach relevant diagnostic, imaging or pathology reports relevant to this referral
This includes specialist reports, chest x-ray, chest CT/CTPA/VQ scan, respiratory function tests, ECG, echocardiogram, holter monitor, ambulatory blood pressure monitor, nerve conduction studies, active stand test

<Ix>

Send this referral to
admin@clinicnineteen.com.au or 03 4059 1919 or Healthlink: nineteen