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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

   W https://nextpracticehealth.com/locations/nsw-westmead

Supportive Cancer Care Referral

Thank you for your interest in Next Practice Western Sydney Integrative Health (WSIH).

Our patient advocates will review your inquiry form and reach out over the next 2-3 days.

Completing this form will allow our patient advocates to streamline your booking process and provide an easier assessment on which practitioner can best assist you.

Patient Electronic Signature is not required unless specifically requested.

Referrer Details


Referrer Name

Referrer Clinic

Referral Date

Appointment Selection

Appointment Type:

Integrative GP
Remedial & Oncology Massage
Tai Chi
Traditional Chinese Medicine & Acupuncture
Yoga Therapy & Meditation

Practitioner Selection:

DR ELLEN PATON (Integrative General Practitioner) - Special Interest in Women's Health, Breast and Cervical Screening, Holistic and Preventative Health and Lifestyle Medicine.
DR NIRI PANDIT (Integrative General Practitioner) - Women's Health, Nutritional Medicine, Mind-Body Medicine, Integrative Medicine and Holistic Health.
JO CURTIN (Oncology and Remedial Massage Therapist) - Oncology Massage, Pregnancy Massage and Remedial Massage.
JUNHYUN (CHLOE) KIM (Traditional Chinese Medicine Practitioner) - Cancer Care, Women's Health, Chronic Disease, Skin Diseases and Pain Management.
MARGARET WU - (Traditional Chinese Medicine Practitioner) - Traditional Chinese Medicine.
MARGERY HELLMAN (Yoga Therapist and Occupational Therapist) - Occupational Therapy and Cancer Care.

Patient History

Reason for Referral:


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Allergies:


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Medications:


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Relevant Past Medical History:


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Medical / Surgical Oncologist:


Medical / Surgical Oncologist Name

Medical / Surgical Oncologist Clinic

Interpreter Required:

No
Yes

If yes, which language.

Relevant Files

Investigations / Test Results included:

Pathology
Radiology
Histopathology
Other

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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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