Please note, the following are Exclusion Criteria:
•	Under the age of 18
•	Receiving active treatment for cancer, infection or fractures
•	On workers compensation, third party and/or motor accident injury claims
•	Prescribed or using high doses of opioids (over 60mg oMEDD)

Patient Details
<PtDetails>
<GenderIdentity>
<PtEmail>				<PtPhoneMob>			<PtPhoneH>

GP Details
<RefDetails>

CHRONIC PAIN PROGRAM OPTIONS 
Please indicate which services are appropriate for the patient:
£	Pain Explained (Online Pain Management Webinar Series with Dr Adele 		Stewart)
	Consultations with multidisciplinary team:
£	Mental Health Clinician
£	Exercise physiologist
£	Dietitian
£	Integrated Health Practitioner (for women experiencing peri or menopausal pain)

Referrer Consent
I have discussed the proposed referral with the patient and
£	The patient is willing to actively participate in the Chronic Pain Program
£	The patient understands that the Chronic Pain Program aims to develop pain self-management skills
£	The patient has given verbal consent to be contacted by GPH’s Chronic Pain Program Team

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Signature:

Medication Details
Attach the patient record and medication list. 
<CurrentRx>