RAPID ACCESS CLINIC 
THE KNEE, HIP AND SHOULDER CLINIC
Referral Form
Private Patients and DVA Gold Card Holders
Call 8275 3364 for an appointment.
Please bring this referral form with you, or your GP can fax it to 8275 3334.

SPECIALISTS
	Dr George Awwad		Dr Matthew Liptak	
	Dr Jonathan Cabot		Dr Gavin Nimon	
	Dr David Hermann		Dr Anthony Samson	
	Dr Mark Inglis		Dr Jason Ward	
	Dr Chi-Meng Ling		Dr Chris Wilson	

PATIENT DETAILS 
Patient Name: [Full Name]						Sex:  M  /   F
Address: [Address]
Postal Address (if different to above): [Postal Address]
DOB: DD/MM/YYYY		Phone: [Phone]			Mobile: [Mobile]
Private Health Insurance:  Y  /  N	Fund Name/Number: [Fund Name/Number]		
DVA Gold Card Holder:  Y  /  N		Card/Fund Number: [Card/Fund Number] 

CLINICAL DETAILS
[Clinical Details]

REFERRING DOCTOR 
Referring Doctor’s Name: [Referring Doctor’s Name]
Provider Number: [Provider Number]
Address: [Doctor’s Address]
Phone: [Doctor’s Phone]			Fax: [Doctor’s Fax]
Signature:					Date: DD/MM/YYYY

NOTE: Patients who have been injured as a result of a motor vehicle accident, work related injury, public liability claim or are not registered with Medicare are not eligible for this service.

FLINDERS PRIVATE HOSPITAL
1 Flinders Drive Bedford Park SA 5042
8275 3333 - flindersprivatehospital.org.au