Resource
snsw Chronic pain management program referral form
GP Referral Form
Chronic Pain Management Program
Referrers Details:
GP Name: GP Practice:
Phone: Fax:
Postal Address:
Patient Information:
Name: DOB:
Phone: Email:
Postal Address:
Best contact (circle): email / phone Permission to leave a message? Y/N
Please note the following are exclusion criteria:
· Patients undergoing active treatment for cancer, infection or fractures
· Patients receiving high dose opioi...