Integrated Care Coordination (ICC) or Integrated Team Care (ITC)
Phone: 	(02) 6937 2000 
Fax: 	(02) 6937 2099
Email: 	ic.intake@marathonhealth.com.au 
Argus (for GPs): 	integratedcareargus@marathonhealth.com.au

Date of referral	<<Miscellaneous:Date>>		
Clients name	<<Patient Demographics:First Name>>	Address	<<Patient Demographics:Address Preferred>>	
Phone number	<<Patient Demographics:Phone (Home)>> <<Patient Demographics:Phone (Mobile)>> 	Date of Birth	<<Patient Demographics:DOB>>	
Next of Kin	<<Patient Demographics:Next of Kin>>	Next of Kin Phone 	<<Patient Demographics:Next of Kin Phone>>	
Carers name	<<Carer's Name>>	Phone Number	<<Carer's Phone Number>>	
Medicare No	<<Patient Demographics:Medicare Number>>	Health Care Card	<<Health Care Card>>	
Pension Card	<<Patient Demographics:Pension Number>>			

Aboriginal and/or Torrest Strait Islander?	<<Patient Demographics:ATSI>>	
Smoking Status	<<Clinical Details:Smoking>>	

Referred by:	<<Doctor:Full Details>>	

Reason for referral
<<Reason for referral>>	

Medical history
<<Clinical Details:History List>>

Other relevant medical history
<<Other relevant medical history>>

Relevant admission history
 <<Relevant admission history>>

Consent provided by Client	<<Consent provided by Client?>>	
Current GPMP / TCA	<<Current GPMP / TCA (if Yes, please attach)>>	
715 Health Check (if available)	<<715 Health Check (if available)>>