Request for Referral to Home Medications Review (HMR)

Request for Referral to Home Medications Review (HMR)

Doctor’s name: *

Address

Phone/Mobile

Fax:

Name

Phone/Mobile

Fax

Organization

Preferred method of receiving GP referral:

Patient name: *

Phone/Mobile

DOB

Address

Patient agreed to receive HMR referral

YES

Reasons for referral request (please select all that applies): *

Please consider whether Choices

Please consider whether the patient identified above would benefit from a Home Medicines Review. We are happy to organize the HMR for this patient upon receiving the referral. Please include in the referral; a current medication list, current medical history and recent pathology results with the reason for the referral, highlighting any concerns that need to be prioritized in the review.