<<Miscellaneous:Practice Letterhead>>

REFERRAL FOR FALL PREVENTION	

Date: <<Miscellaneous:Date>>

Referral to:
<<Addressee:Full Details>>

Patient’s Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Full Address>>
Contact number: <<Patient Demographics:Phone (Home)>> <<Patient Demographics:Phone (Mobile)>>

Patient fall risk factors:
I have recently conducted a fall risk assessment for <<Patient Demographics:Full Name>> and have identified the following factors contributing to her risk for falling:
•	 [PLEASE LIST FALL RISK FACTOR(S) HERE]
•	
•	 
•	

GP recommendations:
I am recommending [PLEASE LIST TAILORED MANAGEMENT HERE] and I would like your assistance in developing a management plan specific to fall prevention for <<Patient Demographics:Full Name>>.
I have attached the fall risk assessment that I have conducted for your reference.

Follow-up:
I would appreciate a summary of your recommendations or patient progress report being forwarded to me.  

The following patient information may be relevant for you to develop the management plan:

<<Clinical Details:History List>>
<<Clinical Details:Family History>>
<<Clinical Details:Social History>>
<<Clinical Details:Prescription List>>

GP’s signature: ___________________________

<<Doctor:Full Details>>