Clinical In-Home Nursing Referral Form

For Hospital Discharge Coordinators, GPs, Nurse Practitioners & Care Managers

Urgency:

1. Patient DemographicsZero travel surcharges within 50km of Gosnells HQ

Full Patient Name *

Date of Birth *

Residential Address *

Suburb & Postcode *

Patient Contact Phone *

Medicare Number

NDIS / HCP Reference (if applicable)

Next of Kin / Carer Name

Carer Phone Number

Funding Pathway *

2. Clinical Services Requested (Select all that apply)

Complex Wound CareMedication ManagementPost-Surgical RecoveryCatheter / Continence CareVital Signs & Chronic CarePalliative Home Nursing

Primary Diagnosis & Reason for In-Home Referral *

Wound Specs / Dressing Protocol / Medications (if applicable)

Known Allergies (or NKDA)

Safety Alerts / Infection Control (e.g. MRSA, VRE, Pets, Access)

3. Referring Clinician / Hospital Coordinator Details

Referrer Name *

Role / Title

Hospital / Practice Name *

Direct Phone / Extension *

Email Address (for clinical notes) *

Provider No. (if applicable)

By submitting this referral, the referring clinician confirms that patient or guardian consent has been obtained for Care N Cure to conduct in-home nursing assessment and coordinate care with the treating medical team.

Referrer Signature:Date: 2026-10-31

How to Submit This Form:

Option 1 (Fastest): Email scanned/saved form + discharge summary to [email protected]

Option 2: Call nurse triage directly on 1300 919 663 for immediate verbal intake.

Clinical intake is acknowledged within 24 hours. Emergency: Call 000.