Priority Referrals
T: +61 3 8862 0000 F: +61 3 9816 8564
www.precisionhealth.com.au		info@precisionhealth.com.au
SPECIALTY REQUIRED:	

Please indicate which specialist consultations are required:
Neurosurgery & Spinal Surgery
<Back pain and sciatica>	Back pain and sciatica
<Neck pain and brachialgia>	Neck pain and brachialgia
<Brain tumour>	Brain tumour
<Spinal tumour>	Spinal tumour
<Carpal tunnel or ulnar neuropathy>	Carpal tunnel or ulnar neuropathy
<Movement disorder>	Movement disorder
<Aneurysm/AVM>	Aneurysm/AVM
<Other>	Other

Priority Workcover Referral Service
<Cervical spine>	Cervical spine
<Lumbar spine>	Lumbar spine
<Other>	Other

Specialist required
<Specialist required>	Pain Management
<Neck pain>	Neck pain
<Back pain>	Back pain
<Neuropathic pain>	Neuropathic pain
<Post-surgical pain>	Post-surgical pain
<Complex regional pain syndrome>	Complex regional pain syndrome
<Other>	Other

Neurology
<Movement disorders>	Movement disorders
<Headaches>	Headaches
<Neuropathy>	Neuropathy
<Trigeminal neuralgia>	Trigeminal neuralgia
<Multiple sclerosis>	Multiple sclerosis
<Epilepsy>	Epilepsy
<Other>	Other	Nerve Conduction Studies/EMG
<Rapid Access Clinic>	Rapid Access Clinic

Psychological Health
<Psychiatry>	Psychiatry
<Psychology>	Psychology
<Neuropsychology>	Neuropsychology

Appointments generally offered within 1-3 weeks

Multidisciplinary Clinics
<Parkinson’s disease and Tremor Clinic>	Parkinson’s disease and Tremor Clinic
<Headache and Facial Pain Clinic>	Headache and Facial Pain Clinic
<Back and Neck Pain Clinic>	Back and Neck Pain Clinic
<Precision Ascend Pain Management Program>	Precision Ascend Pain Management Program	

PATIENT INFORMATION:	
Name:	<PtFirstName> <PtSurname>	Date of Birth:	<PtDoB>
Mobile Phone:	<PtPhoneMob>	Home Phone:	<PtPhoneH>
Insurance Status:	<Private insurance> Private insurance	<Workcover> Workcover	<Motor accident (TAC, MAIB)> Motor accident (TAC, MAIB)	<DVA> DVA
REFERRING DOCTOR:	
Name:	<DrFirstName> <DrSurname>	Email:	<DrEmail>
Practice Name:	<Practice>
Address:	<DrStreet> <DrCity>, <DrState> <DrPostcode>
Provider Number:	<DrProviderNo>	Duration of Referral (months):	<Referral duration (mths)>
Phone:	<UsrPhone>	Fax:	<UsrFax>
CLINICAL DETAILS:	
<Referral letter attached> Referral Letter Attached
<Other clincial details>
	EXCEPTIONAL CARE, TAILORED TO YOU	v1-1
Victorian Locations	Tasmanian Locations
Melbourne – Essendon, Kew, Doncaster	Launceston	
Eastern Suburbs	Hobart	
Northern Suburbs	North-West Coast	
Western Suburbs 	Queensland Locations	
Bayside	Tugun	
South-East Victoria - Cranbourne	Southport	
Mornington Peninsula 	Mackay	
North Eastern Victoria		

PRECISION BRAIN SPINE AND PAIN CENTRE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                1094 Doncaster Road, Doncaster East VICTORIA 3109
T: +61 3 8862 0000                        F: +61 3 9816 8564	ALL CORRESPONDENCE:
PO Box 37054096, Doncaster East, VICTORIA 3109
W: www.precisionhealth.com.au       E: info@precisionhealth.com.au