MR2 pre-admission form

This form is for use by referring doctors and their staff. If you are a patient coming to Epworth, please complete the patient admission form instead.

 

 

  • Patient Information

    Admission campus:*

    Please select campus(es)
    First name:*

    Please enter a value
    Surname:*

    Please enter a value
    Date of birth:*

    Please enter a value
    Home phone:*

    Please enter at least one phone number
    Mobile phone:*

    Please enter at least one phone number
    Work phone:*

    Please enter at least one phone number
    Address:
    Medicare number:


    Medicare expiry date:
    Health fund name:*

    Please enter a value
    Health fund number:

    Please enter a value
    Adverse reactions/allergies/NKA:
  • Booking Information

    Procedure date:*

    Please enter a value
    Admission date & time:
      
    Admitting doctor:*

    Please enter a value
    Surgical assistant:
    Anaesthetist:
    Admission diagnosis:
    Procedures:*

    Please enter a value
    e-CMBS:*

    Please enter a value
    Expected length of stay:
    days
    Accommodation request:



    Intended discharge location:


    Equipment & instrument requirements:
    Investigations/special requirements on admission:
    Loan equipment booked?
    Company name:
    Prosthesis required?
    Prosthesis required description:
    Prosthesis supplier:
    More prosthesis?
    Prosthesis supplier:
    Pathology ordered?
    Specify:
    X-Ray done?
    Specify:
    ECG ordered?
    Specify:
    Consent signed?
    Shared carer involved?
    Specify:

You are about to submit your form. Please make sure that all the fields are filled correctly.


Back Submit

Thank you for completing the notification form. It has been successfully sent to the admission office.


Close

An unexpected error occurred. Please contact Patient Admissions Offices.


Cliveden: 03 9419 7122
Eastern: 03 8807 7772
Freemasons Clarendon St: 1800 337 453
Freemasons DPC: 1800 337 453
Hawthorn: 03 9415 5777
Rehabilitation: 03 9415 5767
Richmond: 03 9426 6155