Referral form for MS Support and Services

 Sensitive data notice: Multiple Sclerosis Limited takes every precaution to protect private patient data. This form is transmitted via a secure connection (SSL), and online data storage is kept to a minimum.
 Referrals can also be accepted for people with a diagnosis of a recognised allied neurological condition. Contact MS Connect on 1800 042 138 for further details before lodging a referral request.
Health professional details (referrer)

(clinic name, hospital, etc)





(office number, mobile)

* = this includes consent from the patient's guardian if they are not able to provide consent themselves.
Patient details (who the service is for)



(mobile or home no.)

.
Address details
Residential address




(ACT, VIC, NSW, & TAS only)
Mailing address




(ACT, VIC, NSW, & TAS only)
Clinical assessment

(inc. date of diagnosis, medication prescribed, name of specialist, etc)


(e.g. availability of carers, support network, etc)

(e.g. pertinent medical documentation, letters from Centrelink, etc)
 Services desired

Note: not all services are available in all states; however we will endeavour to refer on to other providers where appropriate.

(e.g. "client wants to return to work", "immunotherapy information", etc)

(inc. full name, contact no., relationship to patient - e.g. carer)

(inc. agency name, contact person if known, phone no.)


(carer's full name, contact number, relationship to patient, etc)