Community Nursing Referral

Complete this form to refer a client for professional nursing services including medication management, wound care, and health monitoring in the community.

Community Nursing Service Referral Form

Referrer Information

Full Name *

Organization/Practice *

Position/Title *

Email Address *

Phone Number *

Provider Number

Client Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Medicare Number *

Healthcare Card Number

Emergency Contact *

Emergency Contact Phone *

Home Address *

Client has a Representative (Guardian, Power of Attorney, or Support Person)

Nursing Service Requirements

Nursing Services Required * (Select all that apply)

Complex Nursing Care

Nursing System Assessments

Bowel Care & Management

Urinary Catheters & Management

Wound Management

PEG Feeding & Management

Medication Management

Subcutaneous Injections

Tracheostomy Management

Montreal Cognitive Assessment

Continence Assessments

Diabetes Education and Management

Dysphasia Management

NDIS Plan Reviews

Stoma Care

Aged Care Assessments into aged care

Recommended Visit Frequency *

Urgency Level *

Primary Diagnosis & Relevant History *

Current Medications

Specific Clinical Instructions *

Mobility & Home Access Information

Client has NDIS Funding

Check this if the client will be using NDIS funding for services

Supporting Documents

Medical Records/Discharge Summary *

Upload recent medical records, discharge summaries, or relevant test results

Medication Chart/List

Upload current medication chart, prescription details, or pharmacist notes

Additional Information

Consent and Authorization

I confirm that I have the client's consent to make this nursing referral and that all clinical information provided is accurate and current. *

I acknowledge that this information will be used for clinical nursing care delivery and may be shared with relevant healthcare providers and Medicare for billing purposes. *

What Happens Next?

Clinical Review

Our registered nurses will review the referral and clinical requirements within 4 hours for urgent cases, 24 hours for routine referrals.

Initial Assessment

A qualified nurse will conduct an initial assessment visit to develop a personalized care plan and establish Medicare eligibility.

Care Commencement

Regular nursing visits will commence according to the care plan, with ongoing communication with the referring practitioner about client progress.

Aboriginal and Torres Strait Islander cultural imagery

Acknowledgment to Country

Clinicare QLD acknowledges the First Peoples of this Nation and their ongoing cultural and spiritual connections to the lands, waters, seas, skies, and communities.

We acknowledge First Nations Peoples as the Traditional Custodians and Lore Keepers of the oldest living culture and pay respects to their Elders past and present.

Unity in Diversity • Respect • Recognition

Here for you, here for Queensland. Comprehensive healthcare services across Queensland. From aged care to NDIS support, we're here to help you live your best life.

0428 950 043

Hello@clinicareqld.com.au

Queensland Wide