Burns Referral

To: Dr Jason Brown

The patient may also be seen by Dr J. Miller, Prof M. Muller, Dr K. Towsey, Dr E. Vujcich, Dr C. Lisec
Referrer Details
Date*

DayMonthYear
Referring Clinician*

First NameLast Name
Position
Provider No.
Referring Facility*
Contact Phone No.*
Contact Email*
Patient Details
Patient's Name*

First NameLast Name
DOB*

DayMonthYear
Age (must be >14 yrs)
Sex*
Hospital UR Number
Patient's Phone No.*
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Injury*

DayMonthYear
Mechanism of Injury
First Aid

YesNo
Tetanus Immunisation

Within 5 yearsBooster given
Current Proposed Treatment and Follow-up
Consent for Photos Obtained from Patient or Substitute Decision Maker?*

YesNo
Consent Type

VerbalWritten
Photos

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