CQHHS SOPD REFERRAL FORM - Gladstone Hospital
Central Queensland Hospital & Health Service (CQHHS)  
Secure electronic transfer for CQ Referral Centre
Medical Objects: (GQ468000091)
HealthLink EDI: (qldglare)
Or, fax to the CQ Referral Centre: (1300 017 155)
The above fax number cannot be used for Emergency Department or Mental Health Alcohol and Other Drugs Services
For CQ condition-specific referral criteria, visit CQ_HealthPathways

REFERRAL INFORMATION: 	
RE: <PtFirstName> <PtSurname>			         
DOB: <PtDoB>
Referring GP: <DrName>                                                            
Phone number: <DrPhone>
Reason for service request: <Reason for service request>
Service Requested: <Service Requested>                                  
Referral Date:<Referral Date>
Service Provider - Rockhampton <Rockhampton Hospital> 
Service Provider- Gladstone <Gladstone Hospital>
Service Provider- Biloela <Biloela Hospital>
Priority: <Priority> 
Is your practice Telehealth enabled? <Is your practice Telehealth enabled?>
Request for use of telehealth if clinically appropriate? <Request for use of telehealth if clinically appropriate>

REFERRAL LETTER: 
<Referral Letter- please detail reason for referral>

CONSENTS: 
Does patient consent to referral: <Does patient consent to referral?>
Patient is willing to have surgery if required: <Patient is willing to have surgery (if required)>
Are you the patient's usual GP? <Are you the patient's usual GP?>
If no, patient's usual GP: <If not, please provide patient's usual GP or Practice>

CONDITION/ SPECIALITY SPECIFIC CLINICAL INFORMATION- CQ HEALTH PATHWAYS	
HISTORY AND EXAMINATION: - 
Medication list: <SelectedRx>
Investigations relevant to this referral- results <3 months old at time of referral <Ix>
Imaging and reports: 
How have medical images been transfered: <How have images been transferred?> 

STANDARD CLINICAL INFORMATION 	
Allergies/ adverse reactions: <Reactions> 
Immunisations: <Imm>
Observations: <Observations>
Family History: <FamilyHx>
Social History: <SocialHx>

PATIENT INFORMATION 	
IHI: <PtIHI>
Name: <PtTitle><PtFirstName><PtSurname>
Date of birth: <PtDoB> 
Gender: <PtSex>
Indigenous Status: <PtEthnicity>
Occupation: <PtOccupation>

Patients Contact Details
Residential: <PtAddress>
Postal (if different from above):<PtPOAddress>
Home: <PtPhoneH>
Mobile: <PtPhoneMob>
Does patient consent to SMS contact? <Does patient consent to SMS contact?>
Interpreter required: <Interpreter Required>
Preferred Language: <Preferred Language>

Alternative Contact / Carer Details 
Name: <NOKName>
Relationship: <NOKRelation>
Phone: <NOKContact>
Are there custody or guardianship issues? <Are there custody/guardianship issues?>
Details of custody/guardianship issues: <If yes, details of custody/guardianship issues>
Is the child in and out of home (foster) care?<Is the child in and out of home (foster) care?>
Name of child safety service centre: <If yes, name of child safety service centre>
Does the patient have an advance care plan? <Does the patient have an Advanced Care Plan?>
Does the patient have eduring power of attorney?<Does the patient have enduring power of attorney?>

Insurance Information: 
Medicare number: <PtMCNo>
Medicare expiry:<PtMCExpiry>
Pension number: <PtPensionNo>
DVA number: <PtDVANo>
Health fund: <PtInsFund>

REFERRING GP's INFORMATION 	
Name: <DrName>
Provider number: <DrProviderNo>
Practice details:<Practice>
Address:<DrAddress>
Phone: <DrPhone>
Fax: <DrFax>
Email: <DrEmail>

I look forward to hearing the outcome of this patient's consultation. 
Yours Sincerly 
<DrName>