CRGH Burns Unit Referral Form

* Required Fields. Please submit your application by clicking the 'SUBMIT' button.

For urgent or potential admission, please call the burns registrar on 97675000

Please click on the link for retrieval and referral criteria. NSW Burns transfer guidelines

For outpatient referral complete this form.

Please note: Referral does not guarantee an appointment. Please ensure the patient has an appointment for local wound care.

Refer to Kids Burns 02 78250000
schn-chw-kidsburns@health.nsw.gov.au

If the patient resides in a different LHD in NSW, please refer to RNSH 02 99267111 NSLHD-BurnsConsult@health.nsw.gov.au

If the patient resides in a different state, please refer to the relevant burns unit

1st trimester
2nd or 3rd trimester

All referrals will be triaged within 2 business days. Referral does not guarantee an appointment.

Please consider local management for minor burns: Minor burn management

Ensure the patient has a local follow up appointment.

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Referral Details

Details of person submitting referral.

First Name *

Last Name *

Phone *

Email *

Details of Referring Clinician

Referring Clinician Name *

Referring Clinician Provider Number *

Referring Institution *

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Patient Details

Title

Other Details *

First Name *

Surname *

Date of Birth(DOB) *

Street Address *

Suburb *

State *

Postcode *

Patient's Phone Number (mobile preferred) *

Patient's Email

Contact 1

Name

Phone Number

Relationship

Contact 2

Name

Phone Number

Relationship

Background Medical History *

Regular GP

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Patient Demographic Details

Gender

Does the patient have Aboriginal and/or Torres Strait Islander origin?

Interpreter required? *

Yes No

Preferred language *

Financial Status

Medicare Work Cover DVA Corrections
Student Overseas Other/unknown

Medicare number *
(please provide if available)

Medicare Card Placement Number *

Medicare Expiry Date *

Claim Number

DVA Number

DAN Number

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Injury Details

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Safety and clinical risks

Allergies

Yes
No
Unknown

Please Specify

Infectious Disease

Known Multiresistant Organisms
Infectious disease

Please Specify

Security risks ( e.g aggression)

Yes No

Please Specify

Hazardous Drugs (e.g. cytotoxic)

Yes No

Please Specify

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Plans

Current Treatment Plan (Type of dressing/s applied, frequency of change, blisters incised and drained etc)

Follow up plan (Examples: GP appointment within 3 days, Follow up at Burns outpatient within 2-3 days, Telehealth burns support etc)

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Wound photos

Please provide wound photos. This will assist with triage

Can you provide wound photos : *

Yes
No

Upload/Attach a file - (max. 6) (pdf): *
Please ensure the file name does not include any special characters.
When uploading multiple files they must be selected at the same time from the same location. i.e. your Desktop.

If unable please explain reason why. *

Required!

CRGH Burns Unit Referral Form

Referral Criteria

Referral Details

Patient Details

Patient Demographic Details

Injury Details

Safety and clinical risks

Plans

Wound photos