Second opinion pharmacist service
ReturnToWorkSA and SA Health Drug and Therapeutic Information Service (DATIS)
PATIENT DETAILS (MANDATORY) 	
Surname		
First name/s		
Date of birth 		Gender	 ☐ M / ☐ F / ☐ Other	
RTWSA claim number		
REFERRAL (MANDATORY)	
☐ Telephone reply 
☐ Email reply  (NB: not a billable service)	☐ Request for in clinic discussion with doctor	☐ Request for in-clinic consult with patient	
Reason for referral	

	
Timeframe for service 	
☐ 0 - 2 business days	☐ 2 – 5 business days	☐ 1 – 2 weeks	☐ 2 – 4 weeks	
ADDITIONAL INFORMATION (OPTIONAL)	
Clinical history	

Current medication list 	

	
DOCTOR DETAILS (MANDATORY)	
Name		
Signature		
Date of referral		
Fax to (08) 7425 8477 or email health.DATIS@sa.gov.au
For further information please call (08) 7425 8444