wENG0109'pVRES0100PICTn@~ke ^^.. HH.. .. @@..fpng appl..HH PNG dexaPNG  IHDR..W+7gAMAܲ cHRMz&u0`:pQ< pHYs  IDAThՙlNj*EeH!T٫HB  DiQ\(-h nJUD^! 2,$\P[. !7o?.sM|}#ԩ[ϟ/*TZJ^|Eꫯ?_͛'RfMaS0WΝߑӧ + T੩GOK[QabJUV q9R{yO>~9XMo^ڸqXZP~hS+X_bO<8P`Qvg#͛7ˢE$==]}7IܬZEg`B˜=bO8L.~z-̙qgyWaÆ.hSQFI=s`M6m~cV/p$ Çˣ>.i&e˖ޫ*III*'J>}AW^yE&M$hСtRyDŽ5˥*4Gz)EYh„ ҸqcC]߼ySJzpԭ[םo̙2n8;w2H>2E~I:_Dx }0.TbŊb]vǏo|wjժ:/H8FSSSC] K^qަp\ZWIDATC|饗dɒ% MJ7eyw }5#<d…2|pW^2k,cȐ!2b5X ҟʸ .]?. GdffeՒ-[l]viێ;-,_\Ɠ믿vmʕr z<[oɓJ*W8LD$ 8,,LjԨn ]6,ݻW\NN|ЇͮYFs U g*76~Ǧ"r|{ƉD80\tI?ȏ?(.\6={V(lSx|wM3DT[Jz:tƈ4ѿ dT|Ml]:tHEٳg?^#ѣ%>>^u5ᇍ5ULuMӶuVoT o۶Mh!ܹSyofɵmV/׉%@ ^JOfwV֭O?3e.]0/ '>> JˤDd4Jѣ '``<TYoV{BONvz$>c ow֕Vڒp./ތwP.pR+\IuQ#ȃ>Y1@W `@7P]&"[=%!xmw.o# M.2emÆ suuR^=m>_o>UGCi ^Vo':uʉ+A7\$s;Zju %m1l xmk޼c?{l.60H_{t0=ݺus'db,[ĨԷhB>S˴AI4 }9%QJ8:b e]LIDAT  ׃ĻtbU8?Q/SbB ߂Ҁ}A9ubIfByuC=T"p@-((PbH(uH>ڵxi%R[p<_|%@Q8r ^|Y%ܺuK]jZT/~8 '`[ AR岜NZIE6aZZN@P`@F< 溂kfaa V0Dx=>7q-F8ERE<(bBcz<%Z# ;`<"$ӦMs~EC>%$gϞIxN_+J. 曀czN&$$(wnOMwN{.""BBx/.>Nm-M$qn&ȚxFD ,5u9N}?Tǭ{!d!1fanϻQbH *`8Y{A|!KvG4E2tGQCqe^={#&Jp60h/Wp0oYDD'a̘1 00}T͉7[䶖Peĥ%_xU/= DQI{l[}Pe Tܨ&kzܸzANܬQN+KNG ?%Jf c4 ?+:ـenRD(._}w!-m@X &+,p&B.%)!F)c> 5V6p@@C @$@H@l@@@@@ @D@h@@@@  REFERRA L/ APPOINTMENT-MAKING INSTRUCTIONS: Where corresponding fax or phone number appears next to Clinicians name:  @#h$@1. Where Fax option, fax to: (02) 9382 0422 OR  post to:  Level 2, Campus Centre, Barker St, RANDWICK 2031 @@$#2. If phone option, patient to phone the number provided for appointment (or GP for urgent cases) @$@H@l@@@@@ @D@h@@@@ >AAA>AAB`  TO:>A0A0A >A A C*>AACF>AACb>AAC>AAC>AAC>AAC>AAC>AAC>AACԀ>AAC>AAC>AAC @$@H@l@@@@@ @D@h@@@@ SPECIALTY / CLINIC NAME / DR CLINICIAN: ] 5OBJ / ] 5OBJ / ] 5OBJ  @$@H@l@@@@@ @D@h@@@@>AAA  FROM:>AAB`>AAB>AAB>AAC >AAC*>AACF>AACb>AAC>AAC>AAC>AAC>AAC>AAC>AACԀ>AAC>AAC>AAC @@@@@h@D@ @@@@@l@H@$ REFERRAL SOURCE ] 5OBJ  Provider number: ] 5OBJ ! E-mail:  Tel: Fax: Signature:_________________________ Referral Date: ]R>.Date and Time26/06/2006 @$@H@l@@@@@ @D@h@@@@ (The patient and referring doctor will be sent a pre-appointment letter by mail, notifying of appointment within ten (10) working days)>AAB  PATIENT DETAILS>AAB>AAC >AAC*>AACF>AACb>AAC>AAC>AAC>AAC>AAC>AAC>AACԀ>AAC>AAC>AAC @@@@@h@D@ @@@@@l@H@$ Mode of transport to outpatients (if known): WorkCover: >AAB Y / N Medicare Eligible: Y / N Has the patient previously attended Randwick Campus: Y / N MRN: ] 5OBJ& ] 5OBJ ] 5OBJ ] 5OBJ, ] 5OBJ+ Sex: ] 5OBJ D.O.B: ] 5OBJ Telephone: (H) ] 5OBJ (W) ] 5OBJ! (M) ] 5OBJJ  (Please nominate preferred contact number).  Medicare Number: ] 5OBJ' ] 5OBJ Marital Status: ] 5OBJI Language Spoken: ] 5OBJ@ Nominate Language/Dialect: Interpreter Required: Y / N @$@H@l@@@@@ @D@h@@@@ DVA Number (if applicable):] 5OBJ# Plan Type (colour): Gold / White  >@@C  CARER DETAILS: (Wherever possible for Cognitive Disorders Clinic/consent provided to contact carer) >AAC >A`A`CԀ>AAC>AAC>AAC @@@@@h@D@ @@@@@l@H@$ Name: ] 5OBJ% Address:  ] 5OBJ% @$@H@l@@@@@ @D@h@@@@ (Please nominate preferred contact number).>@@CF  >AAB  REASON FOR REFERRAL>AAC >AAC*>AACF>AACb>AAC>AAC>AAC>AAC>AAC>AAC>AACԀ>AAC>AAC>AAC @$@H@l@@@@@ @D@h@@@@ @$@H@l@@@@@ @D@h@@@@Length of Referral:   CLINICAL URGENCY >A0A0B @@@@@h@D@ @@@@@l@H@$ Earliest available appointment as per specialty clinic review. @$@H@l@@@@@ @D@h@@@@>AAA  PAST HISTORY (Please attach further pages if required)>A0A0C>AAC>AAC>AAC>AAC>AACԀ>AAC>AAC >AAC @@@@@h@D@ @@@@@l@H@$ @$@H@l@@@@@ @D@h@@@@ ]hhZ5OBJHTOKNXTRN ShowHistory_Short  CURRENT MEDICATIONS >AAC >AAC*>AACF>AACb>AAC>AAC>AAC>AAC>AAC>AAC>AACԀ>AAC>AAC>AAC @@@@@h@D@ @@@@@l@H@$ @$@H@l@@@@@ @D@h@@@@]ddV5OBJDTOKNXTRNP Show_Scriptso  >AAB`  RECENT INVESTIGATIONS>A0A0C >AAC*>AACF>AACb>AAC>AAC>AAC>AAC>AAC>AAC>AACԀ>AAC>AAC>AAC @@@@@h@D@ @@@@@l@H@$ @$@H@l@@@@@ @D@h@@@@<<Double click Pathology Results in Expressions tab to insert results>> @@@@@h@D@ @@@@@l@H@$ @$@H@l@@@@@ @D@h@@@@  OFFICE USE ONLY>AAB>AAC >AAC*>AACF>AACb>AAC>AAC>AAC>AAC>AAC>AAC>AACԀ>AAC>AAC>AAC @$@H@l@@@@@ @D@h@@@@>LL(<tD X LvLvr HHr rL.@@rcpng applrxxKPNG pnggPNG  IHDRr^fsRGBgAMA a cHRMz&u0`:pQ< pHYsttfxJIDATx^Y̾oRS%jlK L6-^eDb;:A @` ^:'U "<@hcC`$hH"V@fʛ%B`ph $|@`f%Zf? `y?\|M*Lsz寛5!uKEg"$*˒]3wn"wD\o~=w7yto(@@ڵRt>C F+͚YZĠJ^,:c{jLZsx7S:XeVFT@+- CB+=MRjT)Yjյ_ /%8v]PS]ۃJ\ZLkJWKƊCs|ܮ=ph^9 T @VZrqo% [n=(*Et26yDZj&^ׅ.xV٦ L)H' 9 kg,Un7KNE1nVVV+J+M (9?Zy\S@`8;2w(핺VK5vFVXL}SηkJ%qn3Kӑhe{*A},ҟN$-|`ٴRwf}t$g @8N+Fig*jiAaZYEƟVnVZd$ ;ʫ b;җ!.'ndX>[)4\UB`(1TLTrMFVy$xq ! J++m톳(=l[k+[u!lהre۷Mb7dryoVJs(߰h N!Qje +hsgh Y8ZxpB5ytLrUsxKu <8 x' Th $3M(z*ipD4`Y}Ϭ.J=(S+| g4x@g_ީh?Zy2`n@@VDBݧ/532Aib˰Lۯdx Z.z"V+Z9T'V~@VDq@;;8Нf8cgeѶ_v礚8PUXv}*ٿ=gͨޒ>`d7_;CzkO~\dC~5F8[(M8Jc6EXV~=-ChJ+J U\֬N %q ;I+=?S{lwu^g ٞm1VͷVAh6>oQ&>C?dY\ PRu`uz<n/%{<pi޳Fҧ3-Z2 Yd)}V)ZM?)W ~M=ycc!2X^X+UacL(d?CG|ރje-1 pVfbZj_=RC5[TXied#_bje[7զ"sDžPX}2z٧YTw9^޼%che߸4@`jZWϖ$1S pH= *%qzV);E+??"Wے^7j\#^FLPO VB=ȌUO L}<ʩ ʰlR7=e}e 5=|ҜIIn2#o8=7$7pPƩE 5v3 JZ ]i/^JiWutw3LOo\ 052eJTtJg=jdеT+ZYôieƔ+_NlU' ޜZ9< pZiu92/\Ӭ̂1\B꯾ ǡSr3U,D[Ul)7n&d>5pj-*;<~_.{zI  LM`Vz|lo-Jq¬b QYt-Jpd{Jp($ޗ@݋b7Htf)S sYީsrȈgYf_wA@Z2'XFS)l覼-J+O6V+-2HG 0ܧ! H*RudiME/䪕Nȑ9"Sb53rd6-STki"Ԧ!F(B7 03r7G/:o^ @@"Ɣ 01&N.]F'$$~܋Zy|[@`(hP"XܞZy!@_%ZonNG'6~uڇM9{g/wk_S& ln.0 2 C&U ܏ZUkhVEUUKU+74n^TD/#V^ JE!׽"&..4iw}5{邌I*AC!1@[ke4=|V[hʿ&ACW8%w; l@hI#d@.\j+)KU+<4ZyOZyeڀ DB+E5ƫ6oZG⡮&ą=mYQ̩?[>>٩?/Д$Xh%@J[{Z)/D+VLv!V+"nGB+Kvo3#.,\9`\\hle$}S\AܰvC`h@ VIKv2[2>H=Zɇ @+gL  hey #"VE@W@+LMx %h, <2ψ+ ~H 6EE@ xJ@?GDܖM=!F=3,Y2I? hzҌxshm׽赱?Ďhfyѐ% ]!C0r@gإ7ʜh/(*Ҟi_ٓSG;n"g dyhmRMG!Th_ +7+-rsD~xׅ5d? ?7z@+gN 4keP2JUiQ@c?P@zL".^j'& p3hNw!4keeҖ7[VIpC_Uچb1˔)KU+]4<*hHb>9 @ ֦WEWa=[i&\ e3Lx2x<4rDS2\>B>h'VN&C+u=ϯULufkooFX|5}l`]trb=&%VNX@B+E߮Wf\|rJUV>[m)PYW-d#u*qJnX4È8Zy._@`t*oѮ9M랭tuy^1k1FM=BE+S:=)g(w S Kd0@@V b.W;L=آzeV{oU1XʹC@`C@+JB"Ш Eԧ!Bf'0sewsQ{S0]~SoT֗D We{ >z he4@Ze^n^&{(lvU+b^3ieh,Jrn%@`Ph堉#l@;d>B`h<'tRJ 05r9@`lh#z܍Zy_@` h@"T@d@Zmj  @@+M Ah%cHJQ^<#cƐ&N5y8/2J3b Ps; 9J ^Ϋ٥ށ;Vj+Ec@ƒ@WC@V>ŷ}^ @_+K^ҼmNjp4'VϘ 4Vgr}Zg^ni|Uqd6I3/D@EF+?ʟ=?/JO%]/,>,{{J9"VNN:EJ+廪 ]`t^wp}Y\&J+ʹ,=C@R|eZ(z%Z#24@+@ʏʇf6I`![%5END+Zyh PON+2]sV7j,e[Jf@+;NAw'Pfyrߒ`! ;w6tW{ y:V}%@3JcisٳrmmNo8j93h4LC&t@V&;egݕJh|ݚZyy@o%ZwN٦`F9C=@+{A!1@[he!0@@ V2, tK65@#@+GBT+%VvV2 DD+n^]BdTl!_jj,{fu+MjO! Ti庭ҡ{捤cx ݷCG-Zɨ -:\ߧi˼!J{.yãŻMA!@[ZYs28;:HIZRv`h%C@*21;_}VJw:>i<w}Y 0@ZYJ \NJ+[%#{ZV?g!R,,}^!C f$PvJe&:\\hX}dʽ vJS4x;0q`-N GZ?ZV2_%V~?CH`(N6N=(;J90uɎ @che!4@La";|IX>#e'Q|R\c˓l݇@SD} 4iG縵9qUw2V)ܦyBnG@+IaBw$Шʹ%[-149n?%]t J o@+)=!Pt@@+O!%VΛ[z 3f>A@+'I$݀M7I4݄F$V5b} =='ix"/B @K}Wvo@m@}慨 ZȀ - @+%P^!66ආ[;=~@3&y 斞A(JɿE2&躙A H]׍L`z#hG/gD ܆@Vj@+슒V?BIx\WfQE+D@!ЦLtNw8T iyF]0oTxVY%Lƀ#Vǒ;A8@V&&},,{ H0h2ÑZY_,v!I( ]7>U?j̖6s1. WE;JqOAJeLʙI_ kߡa-b̿gsP*`(xVz<Z9v@Vִ>;&fy4Yf#ڊrLO+E߮W<[9sZU:KL+cT[/SC>EWZ)^16#/dA V~:mB("PlyZ76rO񢠸L{vS*)@K´zWE# p δ@@V +vj/I6[1O*UO-wʣf곕ێozM&l JW[ PƼYd=^PJkQLu0ܞ/F+Bhe!(. p=>:Z @+%Vvh%@nSC`Z 0rl+ @1@[V" @ }eK`, %$x!0@g+F"V-bV2 tKD+sߝvw&O*|j3r3$0@\h|; ڵ큑'{iJd(@@VzH-IeB#0@kʯa@9ZMw;ZW>%Ҧ{Cs@+#$Ю1m"ZuNHrʡD p 4@ 'L{Vd@`^h弹g`:1gV?lFz #C+}qt׀EG6 ܁Zy,G@`P;ҳC*MX >X!l@! @@$ЪV#&DQj%h%V}N'P98ET^YlVd @`hI"D@ڵґE*m 3J򮣍~C`?r?C@$%ZyR@5o p*ҴA<" p 8ZyXn @`?r?C\G5-A$iЛ @ PL%k+}!|_V_N0 ^Ɖ >}( J 0rl+ p3EZ_.N?~| x@vw?jV:Rh;:-sOaUds; \-GĵEcchdo6TʩIg [#ikJ~^ Z#k덡s [zsch卓O! i ,E.$\b^z|JWJb7庞λZ{iپzLxWQ %MGL{Bhe!(. p=>kW75i(W<۬~_?9 ϯxnQ5_Hx)F8Zy G@'i_Zjal>/-\su]&'.n 3"pVy޵Xr+ɠ8(6Zam,mE}{6Zy%mڂ PE4L̂YإE+˭%;kۗseVn>^5>@+{@Jc3,&y}ťjeA_zeڢJg+Ók9g&?A>hoCC=8A+c{uށ;/.ٱx[ҥdjlx:&oMBk-V9#DZN&pV:> Aӛ4:곕vUuJ\V bs5 ܺϰZi%yG}Z< IZe9ړx7 UަA#!(Xzj&“ʼnn=3$PC!y䒞@@+K)ʩK c!p7h2N!%P!?A@[he!0@@ V2, tK65@#@+GBT+%Pވm: @+O1%PQ!Q f!(J7t@+;M aA[7x?a˔8 @kʯa@9EʗV~*ڱӹF{@@+m OH+Mh @ CZy%mڂ@+N#VC'@+O-!C<#w!V^ÙV 4@+@kʯa@9heD)@#V2 #eX!ʛ@rBDVh%CZ9Rf Z9x Z9sv#VΗSzLC&t V"tZ9fވw%V5Z9@J n jum Z9w~ 04"rqKr<%V:'P<\\t!  K@+W42a @Bh兰i @ nH0WCG@+ɽ JV+c<[yh PH,e'Pf;'!@[Zi:f 0?rC@`XZSa\ʹIo iݷ'*J>F]hT:!]@gB86yTe; #@ /@I@eZYv p ʴ@Zل7A_"V~ h|9G4iRIG p h-L'!1 c捨!pWh]3O!$!Kd0@@VrN$0܃Zyd̲o{>f ssMVzo׉ fU ( 9|׿]^J2%|T8p޲?O;2he' Gj+EyZjިZ)5g)Z.+^ f㑵tnRƽŵmE_$Z9n@VjUx<"9(,ͭ2RxV1Ik?jM 0ʫnN9׹O(Vz"F #+ ~$vM$#ir/@8N+Wx )juŤNJ3gww-}7"ZJ|̙k~^^짉:=M/?kPIеC87Z9]J 0ôzW+) weZje¨]rV>~~>H\#sOr{`% Ȇ Z9=A+/LThef+EoW̼$klU}|-/޲ :-Hچ.)򦉧ʠV'yRir$xF+?C+(o8w}Zзi[_Z5>( T @V&(%DnWEWT+s"wInCqa1{Z䋌 oo%*Jͻ#ѳEwng?hRJ}RvN=R-*:Q-eJvgV{Er퐧 '! zEbyVwV{CaUyrɜm>bi4oRF'VB8@V2.:]KʤOnq+E-]Vlv2Fez)쳙-$w{O!p|0>@+'J&]f#_+*k*5xbΤ;;;q&\Y؜6 ^һ5f/0*d?ѻBx 1Ou-v%rvT7Y  rjSrs@{h^@G@+ɽ J<'7N&V Ch'V" Bhe!(. Vv شRZk @(%h7 e-&oz:! C!{@+gz Yd~@(A+qf3lBgU~_'7Nr]lx~T  =g 8M+_êJ6AN BZy5qڃ PLH+Ju*VYka0Z+W4G 4BG@+= B|YSt*+6'rμ+@` iJ=^ C+(VJzM΀)>tbh8"R@v*v|0 |  ZpF"V-bnFY.'V@‡f&VΜ]AشRZ@k @(%RӘ2&&ɥk={@+oz  E*] @+o?KD+6޴zvе,0Gar|jSr3U99[P &#$[x۫;g88XsɯWQao ch#>Y~VkWWk~ʡGڵ2V@*E}lJakܴ0{cq̶1Y+=lM^fVM$VQ2hVAZy=sZ PHB+e^5xD#C9ᆉ GV~Ypljt7@+>XI~mԄqF+ 6(5@@^Jȍ_Zل7A@Vn;W.Kk+bs/f/P'I|:T+]n"W&L=כץG$䵜Q5x Ga:? @+'L*]f!ЮQ9վOq V)5Zx휤ϣÀ8|*[ ]-ٰ#Aڇb5 >Zy%ZyTn @;2t4/핺N1+vi薫.x]Nd Fh]Jz*V긶Z#_LᲷv d'|3[k +u10rZɐ -2($4he9I]O+WI+M.. HM˗ KB86;;%Ĺ vM:if5ӟ$9|3ፓ͑d?$V/?.$x"@+@ءWr֨ x+OKvZ{rm 6,$1Qey7&ۀI|-FPIaPՏxfÿs=s3h٥oZz+:6_+e޳ 5:y%xjIwd8ئ# $A V;Zf O=/cvxHDa ihe!,@Z?'[ 땺NI$Ytjlh8,'huIPۤjk$‡C.;Zu֏\Rz״Frv9eٓʺ@*#|@+xq5 kS 2QWER1Zb3v Vj{gqIW2ʿX[YEj&U*KX ?S4VNF:ID+9F$V5bnBI&&!VNHH1 @+-='VB:[@+on: E`JiA @˃ߗD ܓ_V; $i"H@`%V2 tK65J n heKMCL{>_GG(QSZۂ^`Rn9}`R5˫#^k"wA1|5g`q~a](K)Z9jv|[`|oe:eR+"zs*uww_M$Z ۵% {'6?rܾTʑEThK:x,WC S`~6$ȅWn煖ʚp5 V+S5I&rt<AU` {8R]/ȍYg%p lZrvhm|B>J+S͉?LvVU+7qs+>MIpg\dV{P'G&mj>t GQ0zZD+IB#ЮQY^J+:oWTI<*jd^Pg>dɆIVwS(j_doKCJT*QVC8 K`ZL7g5["L$~Nw,9skʥD.ܭj ik 5gfČm8 {-qU7l(:S< -7 qZ{C2Ӝ.(W-6iɥ2Vl]+[[3t,WZuԼBE{;~[i@N+% #&sesNVZi1$ύ_&FѨ_oh娙#n@*RX"_J])&-`\Ulۡ ;яvVC+lQ)q:Vait)WGU+?QJ|E@hJWXvlV4wVCݸ+\N/P6X]$rJ+Ijsۖ1Gt:hui @% O<6mUAٳc!7.(`IAC+@DdP@Z_0=|V)ꥍ&Y>59|=<.^yrCnN@uFYM~@RwRB@ 3ҙV|(&l\ lwV FZ)-YfڞsVV5agSveK!C7Q״l a@[gie\KVVje Z\akeheÜ&"VNLFD+g3%V;"'VNb:S@s@+'3L '!pCh N!QlZ)ȋ @($20qBw&՝O! 0 y @@+M Aa@[%Z)o3."mnجf{IOI/Tu+rgܡ_|He3}K0.a$QZSg Oڑ8>5Y~a|K yڅ %Ю/ӈk>W :bJ+,3eF˭;rTTcJ_F^߸ih-FI%Zyiځ PM]+(m'hm2%f>,IՖckfʄ'ԤZ  '(R1iώPꯡ7UvheXut~^kenG--Vݭu\_خG7va\fnTU'+ؚY c ȎJha'PI;>5Vfk<?{m@:QظV*GP Zjw{+w6<38ݿޤd\|#^{>5Zy(9: vh{M[J v o ?[KkfBT(e'ݱ_k '9B 8L\`* _L[5@vh;ƚt/tvr=(c Q `wXvjeB)-5*m; 655RT,8}j|rnosT|p)ZyDn@ZiݴRvMiRܠXxNi3& Ъ {euSopj[~2Qsq;Zy8I+Zy-oZ PAB+bVRRJ of1ACz#o U|T ң01%g  9]+J;H>>ruWyRSSl%}LZfiT| U]VVb@WhJE{/nZd8*nK|W\gMZDwQಕ =jeV 82dKVVb{⿘V^!({q g x# h$ 2he' V @+HʑElZ)=k @(%iؽٿ&. @8d90 IENDB`