Refer a patient

You can refer a patient. Rotary Oceania Medical Aid for Children (ROMAC) assists children aged 15 years or younger, by bringing them to Australia or New Zealand for life saving or dignity restoring procedures to improve their quality of life. In special circumstances, older children up to 18 years old may be accepted. Cases are accepted only when the required medical treatment is not available to them in their own country. Priority is given to children in the Region covered by Timor Leste, PNG and the South Pacific Islands.

To refer a potential patient to ROMAC, follow these steps:

Referrals to ROMAC should be made using the On-line Referral Form available from the ROMAC website at www.romac.org.au. If website access to this Form is not available a hardcopy version can be obtained from the Operations Director at operations@romac.org.au.
Speak to the patient and their parents/guardians and obtain as much information as possible. The more information you have, and more accurate the contact details you can provide, the better it is. Where patients live in a very remote location try to identify a suitable contact in the closest village/town.
Note that consideration of the Referral cannot be undertaken until full medical diagnostic information is provided. Ideally the Referral Form should be completed by, or in conjunction with, a medical practitioner. The names and contact details of doctors or hospitals that have treated the child must be included. In addition to any specialist medical input, examination by a local paediatrician is highly desirable. The Operations Director can assist by providing details of ROMAC Medical contacts in the various countries that we service.
Supporting medical reports, including scans and pathology reports, and photos are to be sent to operations@romac.org.au
Obtain or take close up photos from all appropriate angles, with one facing the camera for identification purposes. These photos will be used by the ROMAC Medical Panel, in conjunction with the medical information provided, and should clearly show the nature of the medical problem.
Establish from a local doctor whether the child meets our ROMAC criteria, that the child cannot be helped in their own country due to lack of appropriate medical skills or facilities.
If the country has a Rotary presence, identify the name of the Rotary Club closest to the address of the patient, or any church or religious organisation that would be able to communicate with the patient and help ROMAC to follow up with the inquiry. You may have to get the name and addresses, email contact details and phone numbers of the contacts that would be willing to help us follow the case in that country.
We cannot assist a child that is presently in Australia or New Zealand or is a citizen of those countries.
It is important that you make no promises. Only the ROMAC Board can accept a patient for treatment.
Advise the parents (or guardians) that it may take some time for the acceptance determination. Every effort will be taken to get back to the parents as soon as possible in life threatening situations.
Parents and guardians should be advised that cases outside the ROMAC Medical Acceptance Guidelines cannot be accepted.

If you have any subsequent queries relating to progress of the application for assistance by ROMAC, please contact the Operations Director.

I have read and agree to the above conditions.

Step 1: Patient

First Name

Family Name

Gender

Is the Patients date of birth known?

Yes

Date of Birth

Does the patient have a birth certificate?

Yes

Please estimate the year of birth

Height (cm)

Weight (kg)

Does the patient understand English?

Yes

Language/s Spoken

Address

Country of Origin

Nationality

Religion

Step 2: Family Details (Mother)

Please provide the patients mothers details.

Does the patient have a mother?

Yes

First Name

Family Name

Gender

Is date of birth known?

Yes

Date of Birth

Please estimate the year of birth

Address

Email Address

Home Phone

Mobile Phone

Passport Number

Passport Expiry Date

Religion

Occupation

Language/s Spoken

Does the individual understand English?

Yes

Step 3: Family Details (Father)

Please provide the patients fathers details.

Does the patient have a father?

Yes

First Name

Family Name

Gender

Is date of birth known?

Yes

Date of Birth

Please estimate the year of birth

Address

Email Address

Home Phone

Mobile Phone

Passport Number

Passport Expiry Date

Religion

Occupation

Language/s Spoken

Does the individual understand English?

Yes

Step 4: Accompaniment When Travelling

Please nominate who will accompany the patient when travelling; ROMACs preference is the mother.

Who is accompanying the patient?

Relationship to patient

First Name

Family Name

Gender

Is date of birth known?

Yes

Date of Birth

Please estimate the year of birth

Address

Email Address

Home Phone

Mobile Phone

Passport Number

Passport Expiry Date

Religion

Occupation

Language/s Spoken

Does the individual understand English?

Yes

Step 5: Source of Referral

Please provide the details of the individual or organization whom is referring the patient to ROMAC.

Referrer Type

Title

Name of Person/Club/Organisation

Address

Email Address

Office/Home Phone

Mobile Phone

Step 6: Social and Living Conditions

If you have the following information readily available it may assist. If not, it can be provided at a later date.

House Size

in square meter's

Number of Occupants

Number of Rooms

Nearest City with Hospital

Access to Transport

Distance to nearest medical facility (KM)

Travel time to nearest medical facility (Hours)

Medical Facility staffed by

Name, Gender and Age of all siblings

Does patient have access to fresh water?

Yes

Does patient attend school?

Yes

Step 7: Medical Details

Consideration of this Referral cannot be undertaken until full medical diagnostic information is available. Please provide as much medical detail about the patient as possible. Ideally this information should be provided by a medical practitioner. As well as providing details of the specific diagnosis for which assistance is being sought, please also include:

Name and contact details of medical practitioner who made the diagnosis
Full contact details of any other treating doctors and or hospitals attended by the patient
Head circumference (cm) if the child is under 4 years old
Development Age – if delay, please give further information
Any other diagnosis (eg deafness, cataracts, infectious illness, etc)
Any other relevant clinical information

Supporting documents such as medical reports, test results, photos should be emailed separately to operations@romac.org.au clearly identifying the child to which they refer.

Medical diagnosis

Treatment received prior to referral

Contact details of treating doctors

(Name, qualification, phone numbers and email)

Confirmation Submission

Please review the details carefully to ensure the referral can be processed as fast as possible.

Patient

First Name:

Family Name:

Gender:

Is the Patients date of birth known?

Date of Birth:

Does the patient have a birth certificate?

Please estimate the year of birth:

Height (cm):

Weight (kg):

Does the patient understand English?

Language/s Spoken:

Address:

Country of Origin:

Nationality:

Religion:

Mothers Details

The patient has no mother.

First Name:

Family Name:

Gender:

Is date of birth known?

Date of Birth:

Please estimate the year of birth:

Address:

Email Address:

Home Phone:

Mobile Phone:

Passport Number:

Passport Expiry Date:

Religion:

Occupation:

Does the individual understand English?

Language/s Spoken:

Fathers Details

The patient has no father.

First Name:

Family Name:

Gender:

Is date of birth known?

Date of Birth:

Please estimate the year of birth:

Address:

Email Address:

Home Phone:

Mobile Phone:

Passport Number:

Passport Expiry Date:

Religion:

Occupation:

Does the individual understand English?

Language/s Spoken:

Background

Nearest City with Hospital:

Access to Transport:

Does patient have access to fresh water?

Does patient attend school?

Distance to nearest medical facility (KM):

Travel time to nearest medical facility (Hours):

Medical Facility staffed by:

Name, Gender and Age of all siblings:

House Size:

Number of Occupants:

Number of Rooms:

Medical

Medical diagnosis:

Treatment received prior to referral:

Contact details of treating doctors:

Referrer

Referrer Type:

Title:

Name of Person/Club/Organisation:

Address:

Email Address:

Office/Home Phone:

Mobile Phone:

Accompaniment

Who is accompanying the patient?

Relationship to patient:

First Name:

Family Name:

Gender:

Is date of birth known?

Date of Birth:

Please estimate the year of birth:

Address:

Email Address:

Home Phone:

Mobile Phone:

Passport Number:

Passport Expiry Date:

Religion:

Occupation:

Does the individual understand English?

Language/s Spoken:

Refer a Patient

Patient

Mothers Details

Fathers Details

Background

Medical

Referrer

Accompaniment