Sunshine Coast Hospital & Health Service (SCHHS) Central Intake
OUTPATIENT REFERRAL FORM
Secure electronic transfer to: (NQ45600007J)
(Alternatively this referral can be faxed to the Central Booking Office on Fax: 07 5202 0555)
Note the above fax number is for the OUTPATIENT DEPT only and cannot be used for Emergency Department, please refer to the SCHHS pathways link below for further information
HealthPathways (HP) Sunshine Coast and Gympie
Referring Doctor Details |
Doctor:
Treating Doctor.Name
Provider No:
Treating Doctor.Provider Number
Practice Name:
Practice.Name
Practice Address:
Practice.Address
Practice Phone:
Practice.Phone
Phone Fax:
Practice.Fax
Practice Email:
Treating Doctor.E-mail
|
Patient Details |
Re:
Patient Demographics.Full Name
DOB:
Patient Demographics.DOB
Age:
Patient Demographics.Age
Sex:
Patient Demographics.Gender
Preferred name:
Patient Demographics.First Name
IHI:
Patient Demographics.IHI Number
Medicare Number:
Patient Demographics.Medicare Number
DVA Number:
Patient Demographics.DVA Number
DVA Card Type:
Address:
Patient Demographics.Full Address
Postal Address (if different from above):
Patient Demographics.Full Address
Phone (Home):
Patient Demographics.Phone (Home)
Phone (Work):
Patient Demographics.Phone (Work)
Phone (Mobile):
Patient Demographics.Phone (Mobile)
Email:
Patient Demographics.E-mail
|
|
Next of Kin:
Patient Demographics.NOK Name
Next of Kin phone: (M)
Patient Demographics.NOK Mobile Phone
(H)
Patient Demographics.NOK Home Phone
Next of Kin Relationship:
Patient Demographics.NOK Relationship
Guardian/Parent (If different from NOK):
Ethnicity:
Patient Demographics.ATSI Status
Ethnicity
Antenatal baby's Ethnicity:
Ethnicity to be
Interpreter Required:
nterpreter Required:
Preferred Language:
Pre Lang
Does the patient consent to email or SMS contact?
email SMS Consent
If Yes have email/mobile details been provided?
SMS Email Prov
Able to attend appointment at short notice?
Could patient attend
Patient Demographics.Phone (Mobile)
|
Patient Demographics.Full Name
DOB:
Patient Demographics.DOB
Referral Information |
Referral date:
Miscellaneous.Date
Specialty referred to:
Spec Ref
Referral type: Referral Type
Referral TYp
Does the patient require urgent (within a few days) clini`cal assessment? (within a few days)
Urgent Ass
|
Reason for referral |
Reason for referral (including treatment already trialled):
Reason for Ref
Does the patient require urgent (within a few days) clinical assessment.
Urgent Clinical Ass
Reason for Ref
|
|
Have the SCHHS pathways and criteria been checked?
Referral criteria ch
Reason for criteria override:
Reason for criteria
Reason for upgrade request:
Reason for upgrade
Are you Telehealth enabled?
Are you Telehealth
Is a Telehealth consultation clinically appropriate?
Is a Telehealth cons
|
Patient Demographics.Title
Patient Demographics.Full Name
DOB:
Patient Demographics.DOB
Current and Past Medical History |
Allergies/ Adverse Events (including medications / food / latex / environment eg grasses): <Reactions> Medication List: <CurrentRx>
Active Medical and Surgical History: <PMHActive>
Relevant Past Medical and Surgical History: <SelectedPMH>
Immunisations: <Imm>
|
Family and Social History |
Relevant Family History: Smoking Status:
Clinical Details.Smoking
Alcohol Consumption:
|
Observations and Investigations |
Recent Observations:
|
Relevant Investigations: <Ix>
I look forward to hearing the outcome of this patient's consultation.
Yours sincerely
Treating Doctor.Name
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Patient Demographics.Full Name
DOB:
Patient Demographics.DOB