The Queensland Pelvic Mesh Service offers comprehensive assessment and treatment for women with complications from pelvic mesh. Access to resources and referral forms is via the QPMS website.

Health check forms

Care management plan (PDF 221 kB)
Health check: 1 to 6 weeks (PDF 192 kB)
Health check: 2 months (PDF 168 kB)
Health check: 4 months (PDF 169 kB)
Health check: 6 months (PDF 221 kB)
Health check: 9 months (PDF 159 kB)
Health check: 12 months (PDF 162 kB)
Health check: 18 months (PDF 160 kB)
Health check: 2 years (PDF 160 kB)
Health check: 3 years (PDF 212 kB)
Health check: 4 years (PDF 162 kB)
Health check: 5 to < 15 years (PDF 175 kB)
Health check consent 5 to 15 years (PDF 146 kB)
Health check: 15 years + (PDF 227 kB)
Team care arrangements (PDF 220 kB)

Aboriginal and Torres Strait Islander Health Check Templates

Infants and preschool (birth-5 years) PDF
Primary school age (5-12 years) PDF
Adolescents and young people (12-24 years) PDF
Adults (25-49 years) PDF
Older people (50+ years) PDF

central queensland referral templates

Best Practice

Aboriginal and Torres Strait Islander Chronic Disease Management (CCSS and ITC)

ITC referral Yoonthalla Services (Woorabinda) RTF (111 KB)
ITC Referral form Bidgerii RTF (175 KB)

Central Queensland Hospital and Health Service

Alcohol and Other Drugs (AODS) PDF (826 KB)
Breast Screen RTF (620 KB)
Child and Youth Mental Heath PDF (287 KB)
COVID positive HiTH RTF (26 KB)
Endoscopy RTF (172 KB)
Maternity Booking In RTF (61 KB)
Podiatry RTF (136 KB)
Specialist Outpatient Department (SOPD)
- SOPD referral form RTF (108KB)
Sub Acute Care and Chronic Rehabilitation (SACCR) RTF (130 KB)

Early Pregnancy Assessment Service (EPAS)

Referral form RTF (73KB)

Investigations

Lung Screen Australia X-ray Referral Form RTF (150 KB)

Specialist Palliative Care Rural Telehealth Service (SPaRTa)

Referral form RTF (26 KB)
Referral form PDF (49 KB)

Medical Director

Aboriginal and Torres Strait Islander Chronic Disease Management (CCSS and ITC)

ITC Referral form Yoonthalla RTF (77 KB)
ITC Referral form Bidgerii RTF (113 KB)

Allied Health

LiveBetter Referral Form RTF (115 KB)
Live Better Referral Form PDF (258 KB)

Central Queensland Hospital and Health Service

Alcohol and Other Drugs PDF (826 KB)
Breast Screen RTF (620 KB)
Child and Youth Mental Health PDF (287 KB)
Endoscopy RTF (141 KB)
Maternity Booking In Form RTF (43 KB)
Podiatry RTF (115 KB)
Specialist Outpatient Departments eReferral template
- SOPD referral form RTF (107KB)
Sub Acute Care and Chronic Rehabilitation (SACCR) RTF (111 KB)

Colonoscopy/Gastroenterology

CQHHS Endoscopy referral form RTF (141 KB)

Early Pregnancy Assessment Service (EPAS)

Referral form RTF (64KB)

Investigations

Lung Screen Australia X-ray referral RTF (110 KB)

Specialist Palliative Care Rural Telehealth Service (SPaRTa)

Referral form RTF (19 KB)
Referral form PDF (49 KB)

PDF / Word / Online

Aboriginal and Torres Strait Islander Chronic Disease Management (CCSS and ITC)

ITC Referral form Nhulundu (Gladstone and Banana) PDF (313 KB)
ITC Referral form Nhulundu (Gladstone and Banana) WORD (514 KB)
ITC Referral form Yoonthalla (Woorabinda) WORD (252 KB
ITC Referral form Bidgerii PDF (2.0 MB)
ITC Referral form Bidgerii WORD (45 KB)

Allied Health

Live Better Referral Form PDF (258 KB)

Central Queensland Hospital and Health Service

Alcohol and Other Drugs PDF (826 KB)
Breast Screen PDF (195 KB)
Child and Youth Mental Health PDF (287 KB)
Clinical Measurements Gladstone
- PDF (271 KB)
- Word (128 KB)
Clinical Measurements Rockhampton RTF (56 KB)
Endoscopy
- Rockhampton Referral PDF (24 KB)
- Pre-Procedure Screening Tool (258 KB)
Hospital in the Home PDF (604 KB)
Maternity Booking In PDF (1.0 MB)
Nurse Navigator Service PDF (1.7 MB)
Sub Acute Care and Chronic Rehabilitation (SACCR) Clinic Referral Form PDF (1.8 MB)

Central Queensland Respiratory Diagnostics

Respiratory Function Request Form PDF (555 KB)

Early Pregnancy Assessment Service (EPAS)

Referral form PDF (237KB)

Investigations

Lung Screen Australia X-ray Referral PDF (112 KB)
Respiratory Function Request Form PDF (555 KB)

Lung Screen Australia

X-ray Referral PDF (112 KB)

Specialist Palliative Care Rural Telehealth Service (SPaRTa)

Referral form PDF (49 KB)
Flyer PDF (847 KB)

Telesleep Service

wide bay referral templates

Best Practice

Aboriginal and Torres Strait Islander Chronic Disease Management (CCSS and ITC)

ITC Referral for Bundaberg RTF (95 KB)
ITC Referral for Fraser Coast RTF (34 KB)
ITC Referral for North Burnett RTF (507 KB)

Fraser Coast Hospice

Referral Form RTF (261 KB)

Hepatitis C Treatment MDT

SCHHS Hep C Referral RTF (22 KB)

Pulmonary Rehabilitation

Pulmonary Rehabilitation Referral Form – Hervey Bay Physio RTF (117 KB)

Queensland Collaborative Virtual Integrated Pain Centre

Referral Template RTF (99 KB)

Rural Primary Health Services

RPHS Referral Template RTF (71 KB) – Last updated 8/11/2018

Specialist Palliative Care Rural Telehealth Service (SPaRTa)

Referral form RTF (26 KB)
Referral form PDF (49 KB)
Flyer PDF (547 KB)

Vaccination History or Catchup

WBHSS Referral Template RTF (23 KB)

Wide Bay Hospital and Health Service

Colonoscopy/Endoscopy Referral Form RTF (63 KB)
Integrated Care service referral form RTF (22 KB)
WBHHS Request for Procedure BP RTF (17 KB)
Last updated 20/12/2022
WBHHS eReferral RTF (56 KB)
Updated to include Palliative Care – use this option if referring to SPACE service

Medical Director

Aboriginal and Torres Strait Islander Chronic Disease Management (CCSS and ITC)

ITC Referral for Bundaberg RTF (33 KB)
ITC Referral for Fraser Coast RTF (28 KB)
ITC Referral for North Burnett RTF (238 KB)

Fraser Coast Hospice

Referral Form RTF (86 KB)

Hepatitis C Treatment MDT

SCHHS Hep C Referral RTF (33 KB)

Pulmonary Rehabilitation

Pulmonary Rehabilitation Referral Form – Hervey Bay Physio RTF (116 KB)

Queensland Collaborative Virtual Integrated Pain Centre

Referral Template RTF (93 KB)

Rural Primary Health Services

RPHS Referral Template RTF (362 KB)

Specialist Palliative Care Rural Telehealth Service (SPaRTa)

Referral form RTF (19 KB)
Referral form PDF (49 KB)
Flyer PDF (847 KB)

Vaccination History or Catchup

WBHSS Referral Template RTF (15 KB)

Wide Bay Hospital and Health Service

Colonoscopy/Endoscopy Referral Form RTF (41 KB) – Last updated 02/12/2020
Integrated Care service referral form RTF (15 KB)
WBHHS Request for Procedure MD (10kb)
Last updated 21/12/22
WBHHS eReferral RTF (41 KB)
Updated to include Palliative Care – use this option if referring to SPACE service