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Referral to Next Practice Western Sydney Integrative Health (WSIH)

Next Practice WSIH

158-160 Hawkesbury Rd Westmead NSW 2145

P (02) 9145 1290

F (02) 8287 2529

E wsih@nextpracticehealth.com

Referrer Details

Name

Position / Provider Number

Contact Number

Contact Email

Date
Cancer Care Supportive Service
Integrative GP
Mindfulness & Tai Chi
Remedial & Oncology Massage
TCM & Acupuncture
Yoga Therapy & Meditation
Reason for Referral
Interpreter Required
No
Yes

If yes, which language?
Medications
Allergies
Not applicable
Relevant Past Medical History
Not applicable
Investigations / Test Results included
Pathology
Radiology
Histopathology
Other

If other, please elaborate.
  
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Valid file types: JPG, GIF, PNG, and PDF
Medical / Surgical Oncologist
Funding Required
Dry July
Nil (Private)
WSIH Care
First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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