If you are looking to create an EDMP for a patient whom you intend on referring to CFIH, please complete our "Referral form & GP Management Form" which includes a CFIH referral form, medical clearance form, and GP management form all in one.
If you are looking for CFIH's medical clearance or medical monitoring forms, you can find the adult form here and the under 18's form here.
For BN, BED, and OSFED diagnoses, the following additional criteria must be met (below)
BMI < 16
BMI < 13
Weight loss >0.5kg for several weeks
Weight loss 1kg or more for several weeks
Systolic - 90mmHg
Diastolic - 60mmHg
Systolic - 80mmHg
Diastolic - 50mmHg
OR postural drop >10mmHg
OR postural tachycardia >20bpm increase
OR cold/blue extremities
OR prolonged QT interval >450msec
OR rapidly dropping (25% within a week)
Neutrophils <1.2 x 109/L
Neutrophils <1.5 x 109/L
Please bill MBS item #90250-90253 (more information on billing codes can be found here)
agree to information about my mental and medical health to be shared between the GP and the health professionals to whom I am referred, to assist in the management of my health care.
have discussed the proposed referral(s) with the patient and am satisfied that the patient understands the proposed uses and disclosures and has provided their informed consent to these.
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