Author: Fiona Willett

CPC Testing Template V151022

Sunshine Coast Hospital & Health Service Central Patient Intake 
OUTPATIENT REFERRAL FORM

Nambour General Hospital Outpatient Department QHEALTH (NQ45600007J)

(Alternatively this referral can be faxed to the Central Booking Office on Fax: 07 5470 6377)

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Referring Doctor Details:
Doctor: <<Doctor:Name>>
Provider No: <<Doctor:Provider Number>>
Doctor Address: <<Doctor:Full Address>>
Phone: <<Doctor:Phone>>
Fax: <<Doctor:Fax>>
Patients usual GP: <<Doctor:Name>>
Usual GP provider number: <<Doctor:Provider Number>>    	  ===================================================================================
Practice Details:
Practice Name: <<Practice:Name>>
Practice Address: <<Practice:Address>>
Practice Phone: <<Practice:Phone>>
Practice Fax: <<Practice:Fax>>
Practice HPI-O: <<Practice:HPI-O>>   ===================================================================================
Referral Information:
Speciality Name/Department: <<Speciality Name / Dept>>
Consistent with CPC:<<Consistent with CPC>>
CPC clinical override:<<CPC clinical override>>
Referral Reason: <<Referral Reason must be entered >>
Referral Date:<<Miscellaneous:Date (short)>>
Length of Referral: <<Length of referral>>
Is this a TRIAGE upgrade request? <<Upgrade request for an existing referral>>
Reason for Upgrade: <<If upgrade requested please state the reason why>>
Treatment options trialled thus far: <<Treatment options trialled thus far >>
Are you Telehealth enabled? <<Telehealth enabled>>
Is a Telehealth consultation clinically appropriate: <<Is a Telehealth consult option for this patient?>>

Type all your additional information here:

I look forward to hearing the outcome of this patient's consultation.

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Patient Details
Re: <<Patient Demographics:Full Name>>
Date of Birth:<<Patient Demographics:DOB (long)>>
Age:<<Patient Demographics:Age>>
Sex: <<Patient Demographics:Sex>>
Address: <<Patient Demographics:Full Address>>
Phone (Home): <<Patient Demographics:Phone (Home)>>
Phone (Work): <<Patient Demographics:Phone (Work)>>
Phone (Mobile): <<Patient Demographics:Phone (Mobile)>>
NOK/Parent/Guardian (if different from NOK): <<Parent/Guardian (if different from NOK)>>
IHI: <<Patient Demographics:IHI>>
Ethnicity: <<Ethnicity?>>
Ethnicity for the baby (for antenatal referrals only): <<What ethnicity will the baby identify as? (Antenatal)>>
Interpreter Required: <<Interpreter required>>
Preferred Language: <<Preferred language>>
Medicare Number: <<Patient Demographics:Medicare Number>>
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Patient Clinical Details (includes past and current history)
Medication List: <<Clinical Details:Medication List>>
Allergies/Adverse Events: <<Clinical Details:Allergies>>
Recent Investigations: <<Summary:Investigation Results (Selected)>>
Smoking Status: <<Clinical Details:Smoking>>
Alcohol Consumption: <<Clinical Details:Alcohol>>
Patient Notes: <<Summary:Progress Notes (Selected)>>
History of Current Conditions: <<Clinical Details:History List>>
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Family and Social Clinical History
Relevant Social History: <<Clinical Details:Social History>>
Relevant Family History: <<Clinical Details:Family History>>

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Yours sincerely

<<Doctor:Name>>
<<Doctor:Qualifications>>