Referral templates - Central Queensland, Wide Bay, Sunshine Coast PHN

Templates and forms

Find referral templates for practice software below.
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Referral templates

Best Practice Templates

	Central Queensland	Sunshine Coast	Wide Bay
Aboriginal and Torres Strait Islander Chronic Disease Management (CCSS and ITC)	ITC Referral for Nhulundu (Gladstone and Banana) [PDF] – Last updated 15/01/2019 ITC referral [ PDF ] (Bidgerdii) Last updated 09/07/2019 ITC referral (Woorabinda)		ITC Referral for Bundaberg [PDF] Last updated 09/07/2019 ITC Referral for Bundaberg [RTF] Last updated 09/07/2019 ITC Referral for Fraser Coast [RTF] ITC Referral for North Burnett [RTF] – Last updated 31/07/2018
Hospital and Health Service Specialist Outpatient Departments eReferral template	Coming soon.	Information Sheet [PDF] SCHHS eReferral [RTF] Gympie eReferral [RTF] Fax Cover Sheet [RTF] Fax Sheet info	WBHHS eReferral [RTF] – Last updated 16/04/2019
Gastroenterology procedural referral	No additional templates required	SCHHS Open Access Endoscopy eReferral v4 [RTF] View on HealthPathways	Colonoscopy/Endoscopy Referral Form [RTF] – Last updated 17/10/2018 Colonoscopy/Endoscopy Referral Form [PDF] – Last updated 07/01/2019 View on HealthPathways
Persistent Pain	No additional templates required	Referral form [PDF] Entry patient questionnaire [PDF]	Referral form [PDF] Entry patient questionnaire [PDF] Rural Chronic Pain Self-Management Group [PDF] – Last updated 18/07/2018 View on HealthPathways
Children’s Health Queensland	Access templates	Access templates	Access templates
Pulmonary Rehabilitation		Pulmonary Rehabilitation Referral Form [RTF] Pulmonary Rehabilitation Referral Form [PDF]	View on HealthPathways Pulmonary Rehabilitation Referral Form – Hervey Bay Physio [RTF] – Last updated 12/10/2018 Pulmonary Rehabilitation Referral Form – Hervey Bay Physio [DOCX] – Last updated 12/10/2018 Pulmonary Rehabilitation Referral Form – Hervey Bay Physio [PDF] – Last updated 12/10/2018
Hepatitis C Treatment MDT		SCHHS Hep C Referral [RTF]	SCHHS Hep C Referral
My Health For Life	Referral form [RTF] GP Referral Form [PDF] – Last updated 17/10/2018 PEN CS Recipes	Referral form [RTF] GP Referral Form [PDF] – Last updated 17/10/2018 PEN CS Recipes	Referral form [RTF] GP Referral Form [PDF] – Last updated 17/10/2018 View on HealthPathways PEN CS Recipes
SCHHS Clinical Investigation Unit		Nerve Conduction Studies (NCS) referral form [RTF] Electroencephalogram (EEG) referral form [RTF]
Nurse Navigator Service		Nurse Navigator Service referral form [PDF] Nurse Navigator Service information [PDF] Nurse Navigator Referral Criteria [PDF]	WBHHS Nurse Navigator Service Referral [PDF] – Last updated 17/10/2018 View on HealthPathways
Artius Referrals	Artius Referral Template [RTF]	Artius Referral Template [RTF]	Artius Referral Template [RTF]
Therapeutic Referral		QuIHN Therapeutic Referral [DOCX]
Partners in Recovery	Partners in Recovery CQ [RTF]		View on HealthPathways
Ophthalmology			Ophthalmology referral form [PDF] – Last updated 17/10/2018 View on HealthPathways
Vaccination History or Catchup			WBHSS Referral Template [RTF] – Last updated 17/10/2018
Rural Allied Health – Community Health			Rural Allied Health Referral Template [PDF] – Last updated 17/10/2018
Rural Primary Health Services			RPHS Referral Template [RTF] – Last updated 8/11/2018

Medical Director templates

	Central Queensland	Sunshine Coast	Wide Bay
Aboriginal and Torres Strait Islander Chronic Disease Management (CCSS)	ITC Referral for Nhulundu (Gladstone and Banana) [PDF] – Last updated 15/01/2019 CCSS Referral (Bidgerdii)		ITC Referral for Bundaberg [PDF] ITC Referral for Bundaberg [RTF] ITC Referral for Fraser Coast [RTF] ITC Referral for North Burnett [RTF] – Last updated 31/07/2018
Hospital and Health Service Specialist Outpatient Departments eReferral template	Coming soon.	Information Sheet [PDF] SCHHS eReferral [RTF] Gympie eReferral [RTF] Fax Cover Sheet [RTF] Fax Sheet info	WBHHS eReferral [RTF] – Last updated 16/04/2019
Gastroenterology procedural referral	No additional templates required	SCHHS Open Access Endoscopy eReferral v4 [RTF] View on HealthPathways	Colonoscopy/Endoscopy Referral Form [RTF] – Last updated 17/10/2018 Colonoscopy/Endoscopy Referral Form [PDF] – Last updated 07/01/2019 View on HealthPathways
Persistent Pain	No additional templates required	Referral form [PDF] Entry patient questionnaire [PDF]	Referral form [PDF] Entry patient questionnaire [PDF] Rural Chronic Pain Self-Management Group [PDF] – Last updated 18/07/2018 View on HealthPathways
Pulmonary Rehabilitation		Pulmonary Rehabilitation Referral Form [RTF] Pulmonary Rehabilitation Referral Form [PDF]	View on HealthPathways Pulmonary Rehabilitation Referral Form – Hervey Bay Physio [RTF] – Last updated 12/10/2018 Pulmonary Rehabilitation Referral Form – Hervey Bay Physio [DOCX] – Last updated 12/10/2018 Pulmonary Rehabilitation Referral Form – Hervey Bay Physio [PDF] – Last updated 12/10/2018
Children’s Health Qld	Access templates	Access templates	Access templates
Hepatitis C Treatment MDT		SCHHS Hep C Referral [RTF]	SCHHS Hep C Referral [RTF]
My Health For Life	Referral form [RTF] GP Referral Form [PDF] – Last updated 17/10/2018 PEN CS Recipes	Referral form [RTF] GP Referral Form [PDF] – Last updated 17/10/2018 PEN CS Recipes	Referral form [RTF] GP Referral Form [PDF] – Last updated 17/10/2018 View on HealthPathways PEN CS Recipes
SCHHS Clinical Investigation Unit		Nerve Conduction Studies (NCS) referral form [RTF] Electroencephalogram (EEG) referral form [RTF]
Nurse Navigator Service		SCHHS Nurse Navigator Service Referral [PDF] Nurse Navigator Service information [PDF] Nurse Navigator Referral Criteria	WBHHS Nurse Navigator Service Referral [PDF] – Last updated 17/10/2018 View on HealthPathways
Artius Referrals	Artius Referral Template [RTF]	Artius Referral Template [RTF]	Artius Referral Template [RTF]
Therapeutic Referral		QuIHN Therapeutic Referral [DOCX]
Partners in Recovery	Partners in Recovery CQ [RTF]		View on HealthPathways
Ophthalmology			Ophthalmology referral form [PDF] – Last updated 17/10/2018 View on HealthPathways
Vaccination History or Catchup			WBHSS Referral Template [RTF] – Last updated 17/10/2018
Rural Allied Health – Community Health			Rural Allied Health Referral Template [PDF] – Last updated 17/10/2018
Rural Primary Health Services			RPHS Referral Template [RTF] – Last updated 8/11/2018

ZedMed Templates

	Central Queensland	Sunshine Coast	Wide Bay
Hospital and Health Service Specialist Outpatient Departments eReferral template		SCHHS eReferral [RTF]
Persistent Pain	No additional templates required	Referral form [PDF] Entry patient questionnaire [PDF]	Referral form [PDF] Entry patient questionnaire [PDF] Rural Chronic Pain Self-Management Group [PDF] – Last updated 18/07/2018 View on HealthPathways
Pulmonary Rehabilitation		Pulmonary Rehabilitation Referral Form [PDF]	View on HealthPathways Pulmonary Rehabilitation Referral Form – Hervey Bay Physio [DOCX] – Last updated 12/10/2018 Pulmonary Rehabilitation Referral Form – Hervey Bay Physio [PDF] – Last updated 12/10/2018
Children’s Health Queensland here	Access templates	Access templates	Access templates
Hepatitis C Treatment MDT		SCHHS Hepatitis eReferral [RTF]	SCHHS Hepatitis eReferral [RTF]
My Health For Life	Updated Referral form [RTF] GP Referral Form [PDF] – Last updated 17/10/2018 PEN CS Recipes	Updated Referral form [RTF] GP Referral Form [PDF] – Last updated 17/10/2018 PEN CS Recipes	Updated Referral form [RTF] GP Referral Form [PDF] – Last updated 17/10/2018 View on HealthPathways PEN CS Recipes
SCHHS Clinical Investigation Unit		Nerve Conduction Studies (NCS) referral form [RTF] Electroencephalogram (EEG) referral form [RTF]
Nurse Navigator Service		SCHHS Nurse Navigator Service Referral [PDF] Nurse Navigator Service information [PDF] Nurse Navigator Referral Criteria [PDF]	WBHHS Nurse Navigator Service Referral [PDF] – Last updated 17/10/2018 View on HealthPathways
Gastroenterology procedural referral		SCHHS Open Access Endoscopy Referral [PDF] SCHHS Open Access Endoscopy Referral [RTF]	Colonoscopy/Endoscopy Referral Form [PDF] – Last updated 07/01/2019 View on HealthPathways
Therapeutic Referral		QuIHN Therapeutic Referral [DOCX]
Partners in Recovery			View on HealthPathways
Ophthalmology			Ophthalmology referral form [PDF] – Last updated 17/10/2018 View on HealthPathways
Rural Allied Health – Community Health			Rural Allied Health Referral Template [PDF] – Last updated 17/10/2018

	Central Queensland	Sunshine Coast	Wide Bay
Persistent Pain	No additional templates required	Referral form [PDF] Entry patient questionnaire [PDF]	Referral form [PDF] Entry patient questionnaire [PDF] Rural Chronic Pain Self-Management Group [PDF] – Last updated 18/07/2018 View on HealthPathways
Pulmonary Rehabilitation		Pulmonary Rehabilitation Referral Form [PDF]	View on HealthPathways Pulmonary Rehabilitation Referral Form – Hervey Bay Physio [DOCX] – Last updated 12/10/2018 Pulmonary Rehabilitation Referral Form – Hervey Bay Physio [PDF] – Last updated 12/10/2018
Children’s Health Queensland here	Access templates	Access templates	Access templates
Nurse Navigator Service		SCHHS Nurse Navigator Service Referral [PDF] Nurse Navigator Service information [PDF] Nurse Navigator Referral Criteria	WBHHS Nurse Navigator Service Referral [PDF] – Last updated 17/10/2018 View on HealthPathways
Gastroenterology procedural referral		SCHHS Open Access Endoscopy Referral [PDF]	Colonoscopy/Endoscopy Referral Form [PDF] – Last updated 01/07/2019 View on HealthPathways
Therapeutic Referral		QuIHN Therapeutic Referral [DOCX]
My Health for Life	GP Referral Form [PDF] – Last updated 17/10/2018	GP Referral Form [PDF] – Last updated 17/10/2018	GP Referral Form [PDF] – Last updated 17/10/2018 View on HealthPathways
Partners in Recovery			View on HealthPathways
Ophthalmology			Ophthalmology referral form [PDF] – Last updated 17/10/2018 View on HealthPathways
Rural Allied Health – Community Health			Rural Allied Health Referral Template [PDF] – Last updated 17/10/2018

Other Hospital resources and services

GP plans and forms

GP Plan for Chronic Disease Management

GP Management Plan [PDF]
GP Management Plan [RTF – Right click, save as. Medical Director and Best Practice]

Team Care Arrangements [PDF]
Team Care Arrangements [RTF – Right click, save as. Medical Director and Best Practice]

Combined GP Management Plan and Team Care Arrangements [PDF]
Combined GP Management Plan and Team Care Arrangements [RTF – Right click, save as. Medical Director and Best Practice]

GP Plan for Mental Health

Heart Health Assessment

GP listening to heart beat

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