Physiotherapy clinic referral | Federation University

Given name

Preferred name

Family name

Date of birth

Telephone number * (Please confirm latest phone number with patient)

Address (VIC residents only)

Presentation/Reason for referral

History

Medication

Previous treatment and interventions

Does the patient have a support person or carer?

Partner

Family member

Parent/guardian

Carer

Does the patient need a translator?

Yes

No

Language spoken

What are the patients' current living arrangements?

Lives at home alone

Lives with someone else or family member

Lives in remote location

Lives near other neighbours for example

Any other information

You can upload your referral and/or imaging reports/relevant investigation results here.

How did you hear about us?

Name of person referring

Name of organisation

Email of person referring

Phone number of person referring

Please advise your patient that we will be in contact to arrange an appointment within 2 to 3 working days of receiving the referral. Thank you.

Your privacy

Federation University collects this information to deliver health services to you and to manage your health records. We use the Zanda clinic management platform to securely store and manage your information, so our staff can provide you with the best possible care and support.

We may share this information with relevant health professionals and service providers where it's necessary to coordinate your care or as required by law.

You are required to provide this information so we can assess your needs and deliver appropriate health services. If you choose not to provide the requested information, we may not be able to offer you the full range of health services or support.

We're committed to protecting and maintaining the privacy, accuracy and security of your information. Please refer to our clinic privacy information to find out more about how we collect, hold, use and disclose personal information.

Contact us or email privacyofficer@federation.edu.au if you have any questions.

Referral Information form

Your privacy