Get the free Emergency Department Referral Form - Sir Charles Gairdner Hospital

REFERRAL TO EMERGENCY DEPARTMENT (Please contact ED with patient details, then fax referral to ED and provide copy to patient) PATIENT DETAILS Name: Next Of Kin: Address: Relationship to Patient:

How to fill out emergency department referral form

How to fill out an emergency department referral form:

1. Start by gathering the necessary information: Before filling out the form, make sure you have the patient's personal details, including their full name, date of birth, contact information, and insurance details. It's also important to have the referring physician's information and any relevant medical history.
2. Provide the reason for referral: Indicate the primary reason why the patient needs to be referred to the emergency department. This could be due to a specific medical condition, symptoms, or an urgent situation that requires immediate attention.
3. Include relevant medical information: In this section, provide a concise summary of the patient's medical history, current medications, allergies, and any recent relevant tests or procedures. Include any pertinent information that can help the emergency department staff understand the patient's condition better.
4. Specify any special requirements: If the patient requires specific accommodations or if there are any special considerations for their care, such as language preferences or mobility issues, be sure to include these details in the form. This will help the emergency department staff provide the necessary support.
5. Provide contact information: Include the contact details of the referring physician, including their name, phone number, and email address. This allows the emergency department staff to contact the referring physician for any further information or clarification if needed.

Who needs an emergency department referral form?

1. Patients requiring immediate medical attention: An emergency department referral form is typically needed for patients who require urgent medical care. This includes individuals experiencing severe injuries, acute symptoms, or medical conditions that cannot be effectively managed outside of a hospital setting.
2. Referring physicians: Referring physicians, such as primary care doctors or specialists, who identify the need for emergency care for their patients, should fill out an emergency department referral form. This facilitates communication between the referring physician and the emergency department staff, ensuring a smooth transition of care.
3. Other healthcare professionals: In some cases, healthcare professionals from allied disciplines may also need to complete an emergency department referral form. This could include nurse practitioners, physician assistants, or paramedics who are involved in patient care and need to refer the patient to the emergency department for further evaluation or treatment.

Remember, it is important to follow any specific guidelines or procedures provided by the hospital or healthcare facility when filling out an emergency department referral form. Timely and accurate completion of the form will help ensure appropriate and efficient care for the patient in need.

For pdfFiller’s FAQs

What is emergency department referral form?

Emergency department referral form is a document used to refer patients to the emergency department for urgent medical care.

Who is required to file emergency department referral form?

Medical professionals such as doctors, nurses, and other healthcare providers are required to file emergency department referral form.

How to fill out emergency department referral form?

Emergency department referral form should be filled out by providing patient's information, reason for referral, and any relevant medical history.

What is the purpose of emergency department referral form?

The purpose of emergency department referral form is to ensure that patients receive timely and appropriate medical care in emergency situations.

What information must be reported on emergency department referral form?

Information such as patient's name, age, contact information, medical history, reason for referral, and referring physician's details must be reported on emergency department referral form.

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