Hospital Administration Use Only: Affix patient label here

BUNDABERG HOSPITAL  OUTPATIENT REFERRAL FORM v06/17
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REFERRAL: 

Date of referral:<TodaysDate>
Referral validity duration: <Referral validity duration:>
Reason for referral: <Reason for referral>
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REFERRAL TO:

Organisation: Bundaberg Hospital (XB4670000X6)
Clinic referred to: <Clinic Referred To>
Clinic referred to (where no specific doctor has been nominated): <Clinic referred to (where no specific Dr is nominated)>
Address: 271 Bourbong street, Bundaberg Qld 4670
Phone: 07 4150 2222
Fax: 07 4303 8299
Fax (REFERRALS): 07 4303 8299
  
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REFERRAL FROM:

Referring clinician: <DrName>
Organisation: <Referring Practice Name>
Address: <DrAddress>
Phone:<DrPhone>
Email: <DrEmail>
Fax: <DrFax>
Provider number: <DrProviderNo>
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PATIENT DETAILS:

Re: <PtFullName>
Surname: <PtSurname>
Given name: <PtFirstName>
DOB: <PtDoB>
Sex: <PtSex>
Preferred language: <Preferred Language>
Interpreter required: <Interpreter required>
Indigenous status: <Indigenous status>
Australian South Sea Islander status: <Australian South Sea Islander status>
Address: <PtAddress>
Phone (home): <PtPhoneH>
Phone (work): <PtPhoneWk>
Phone (mobile): <PtPhoneMob>
Medicare card number:<PtMCNo>
DVA card number: <PtDVANo>
Compensable status: <Compensable status>
Hospital insurance status: <Hospital insurance status>
Private health insurance fund: <PtInsFund>
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PATIENT CLINICAL INFORMATION:

Current medications: (please list and provide description, dosage, route, dose quantity, frequency and any additional instructions)
<SelectedRx>
Warnings / alerts: <Comment>
Allergies/ adverse reactions: (Please list and including reaction description)
<Reactions>
Recent investigations / test results: (including type, name, date, result status, results)
<Ix>
Smoking status: <SmkStatus>
Alcohol consumption: <AlcHx>
Existence of Advanced Health Directive: <Existence of Advanced Health Directive>
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PATIENT CLINICAL HISTORY:

Relevant medical and surgical history: (including treatments, medications, outcomes, date/time range)
<SelectedPMH>
Relevant social / family history: (including employment, education, home, finances and activities of daily living)
<SocialHx>
<FamilyHx>
Special needs and/or psychosocial issues: <Special needs and/or psychosocial issues>
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USUAL GP (if different):

Name and Organisation: <Usual GP Name and Organisation>
Contact Details: <Usual GP Contact Details>
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ALTERNATE CONTACT(S):

Alternate Contact name:  <Alternate Contact name (First name, Family name)>
Relationship to patient: <Relationship to patient>
Alternate Contact contact details: <Alternate Contact contact details>
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VERIFICATION:

Doctors Full Name: <DrName>
Date:  <TodaysDate>
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Sent via STS Secure electronic transfer to: BUNDABERG HOSPITAL QHEALTH 
Form version: 06/17