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I m portant I nformation for Patholoqy Col lectors

1. Patient must present with a new-signed referral for every series of tests covered by Rule 3Exemption.

2. Advise patient before expiry of current Rule 3 Exemption referralthat a new-signed form isneeded from Doctor if he/she wishes to refer patient for further tests under this provision.

3. Do not collect blood samples on an interim form.

4. Check name of referring Doctor with patient at every visit.

Patient Details Doctor Details

Laboratory Dose Doctor Dose (circle)

Surname: Given Name: Surname lnitial

DOB: Sex Telephone Address

Address Post Code Telephone

Fax:

MEDICARE REPAT WORK COVER Copy Doctor

Surname Initial

AddressTests Requested

Frequency Duration Change of Doctor / Practice Details

Date:

Clinical History

Referral Date: R3X INR RECORD ONLY

DATE DATE DATE

Referral Date: R3X other than INR Record 6visits in 6 months only orwhichever comes first

Test Dates: 1 Test Dates: 1

2 2

3 3

4 4.

5 5

6 6

Date lssued : 211A912010Authorised by: Patient Centres Manager - Clayton

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