Pathway Suggestion Form

Please complete the form below if you would like to propose the development of a new pathway.For LHD Services the proposed pathway needs to reflect the whole of service, particularly those that are multi-centred.

Name

Contact Number

Please include your profession and the service that you work for

Please provide the name of the proposed pathway and its pathway group (e.g. acute chest pain / cardiology section)

Please identify the services and/or departments that would be required in the development of the suggested pathway. Please also provide the names of people to contact if known

Are you willing to be a Workgroup member

YesNo

The Pathway is a priority for

Primary Care / Community CliniciansSecondary / Specialist CliniciansBoth

Please provide information as to why you believe developing this pathway is a priority for south western Sydney

Please identify any service issues related to this area that you are aware of (e.g. unclear referral criteria or poor communication between primary health and hospitals)

Please enter any other information you would like to add here.

Security Code

Enter the code shown above in the box below.