Referral Form

Referral form for the Pathways to Pain Management online program

Section 1 – Patient Details

Full Name: <PtFirstName> <PtSurname>

Date of Birth: <PtDoB>

Section 2 – Referring GP Details

GP Name: <DrFirstName> <DrSurname>

Practice: <Practice>

Provider Number: <DrProviderNo>

Section 3 – About the Program
Pathways to Pain Management is an evidence-informed, 11-module multidisciplinary online education program designed to support patients living with chronic pain.
 Accessible, structured education on understanding and managing chronic pain.
 Practical strategies to improve self-management and daily functioning.
 Designed to complement GP Chronic Condition Management Plans (GPCCMP) and support multidisciplinary care.

Section 4 – Referral
Please select one

I refer this patient to Pathways to Pain Management and confirm this referral is part of a GP Chronic Condition Management Plan (GPCCMP).

I refer this patient to Pathways to Pain Management, not as part of a GP Chronic Condition Management Plan (GPCCMP).

GP Signature:		

Date: <TodaysDate>

Instructions for use
Instructions for Patients
1.	Take the form to your GP
	Bring this printed referral form to your appointment.

2.	Ask your GP to complete and sign
		Your GP will fill in their details, tick the appropriate referral option, add their provider number, sign, and date the form.
	The GP will return the signed form to you.

3.	Submit your signed referral form online
	Scan the QR code below or go to our secure online registration page.
	Enter your details into the online form.
	Upload a clear scan or photo of your signed referral form.

                                             Or visit: https://form.jotform.com/252261550912047

4.	Get access to Pathways to Pain Management
		Once your form is submitted, you’ll be automatically enrolled and can start the 11-module online program straight away.

Instructions for GPs

1.	Complete the referral form
	Print both pages including this instruction sheet 
	Check or Fill in the patient's details, your name, practice, and provider number.
	Tick the relevant referral option (GPCCMP or not GPCCMP).
	Sign and date the form.

2.	Return the form to the patient
	The patient will upload the form as part of their online registration process.
	Patients will handle submission and program access directly.