CQHHS SOPD REFERRAL FORM - CQ Wide
Central Queensland Hospital & Health Service (CQHHS)  
Secure electronic transfer for CQ Referral Centre
Medical Objects: (XR4700000LZ)
HealthLink EDI: (qldrocop)
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 Health Pathways
REFERRAL INFORMATION:	
Re: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
DOB: <<Patient Demographics:DOB>>
Referring GP: <<Doctor:Name>>
GP phone number: <<Practice/Location:Phone>>
Reason for service request: <<Reason for service request >>
Service Requested: <<Service requested>>
Referral date: <<Miscellaneous:Date>>
Service provider- Rockhampton: <<Rockhampton >>
Service provider - Gladstone: <<Gladstone >>
Service provider- Emerald: <<Emerald>>
Service provider - Biloela: <<Biloela>>
Service provider - Capricorn Coast: <<Capricorn Coast>> 
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 wiling 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 no, please provide patient's usual GP or Practice >>

CONDITION / SPECIALITY - Specific clinical information - CQ Health Pathways 	

HISTORY AND EXAMINATION: 
Medication list: 
<<Clinical Details:Medication List>>
Investigations relevant to this referral (results <3 months old at time of referral) 
<<Summary:Investigation Results (Selected)>>

IMAGING AND REPORTS 
How have medical images been transferred: 
<<How have images been transferred? >> 

STANDARD CLINICAL INFORMATION 	
Allergies/ Adverse Reactions:
<<Clinical Details:Allergies/Adverse Reactions>>

Immunisations
<<Clinical Details:Immunisation List>>

Observations: 
<<Clinical Details:Measurements>>

Family History
<<Clinical Details:Family History>>

Social History
<<Clinical Details:Social History>>

PATIENT INFORMATION 	
IHI: <<Patient Demographics:IHI>>
Name: <<Patient Demographics:Title>> <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of Birth: <<Patient Demographics:DOB>>
Gender: 
Indigenous Status: 
Ocupation: 
Patients contact details
Residential: <<Patient Demographics:Address>>
Postal: (if different from above): <<Patient Demographics:Address Postal>>
Home: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Does patient consent to SMS contact?: <<Does patient consent to SMS contact ? >>
Interpreter Required: <<Patient Demographics:Requires Interpreter>>
Preferred Language: <<Patient Demographics:Language Preferred>>  

Alternative Contact/ Carer Details
Name: <<Patient Demographics:Next of Kin>>
Relationship: <<Patient Demographics:Next of Kin Relationship>>
Phone: <<Patient Demographics:Next of Kin Phone>>
Are there custody or guardianship issues?: <<Are there custody or guardianship issues? >>
Details of custody/guardianship issues?: <<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: <<Name of child safety service centre>>
Does the patient have an advance care plan?: <<Does the patient have an advance care plan? >>
Does the patient have an enduring power of attorney?: <<Does patient have an enduring power of attorney?>> 

Insurance Information 
Medicare Number: <<Patient Demographics:Medicare Number>>
Medicare Expiry: <<Patient Demographics:Medicare Expiry Date>>
Pension Number: <<Patient Demographics:Pension Number>>
DVA number: <<Patient Demographics:DVA Number>>
Health Fund: <<Patient Demographics:Health Insurance>>

REFERRING GP's INFORMATION	
Name: <<Doctor:Name>>
Provider number: <<Doctor:Provider Number>>
Practice Details: <<Practice/Location:Name>><<Practice/Location:Location Name>>
Address: <<Practice/Location:Address>>
Phone: <<Practice/Location:Phone>>
Fax: <<Practice/Location:Fax>>
Email: <<Practice/Location:E-mail>>

I look forward to hearing the outcome of this patients consultation. 

Yours sincerely, 
<<Doctor:Name>>