Hospital Administration Use Only: Affix patient label here

HERVEY BAY HOSPITAL  OUTPATIENT REFERRAL FORM v06/17
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REFERRAL: 

Date of referral: <<Miscellaneous:Date (short)>>
Referral validity duration: <<Referral Validity Duration>>
Reason for referral: <<Reason for Referral>> =========================================================================================
REFERRAL TO:

Organisation:  Hervey Bay Hospital  (XH46550004U)
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: Cnr Urraween & Nissen Street, Hervey Bay Qld 4650
Phone: : 07 4325 6666
Fax: 07 4325 6792
Fax (REFERRALS): 07 4325 6638
  
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REFERRAL FROM: 
Referring clinician: <<Doctor:Name>>
Organisation:<<Practice:Name>>
Address: <<Practice:Address>>
Phone:<<Practice:Phone>>
Email: <<Doctor:E-mail>>
Fax:<<Doctor:Fax>>
Provider number: <<Doctor:Provider Number>>
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PATIENT DETAILS:

Re: <<Patient Demographics:Full Name>>
Surname: <<Patient Demographics:Surname>>
Given name: <<Patient Demographics:First Name>>
DOB: <<Patient Demographics:DOB>>
Sex: <<Patient Demographics:Gender>>
Preferred language: <<Patient Demographics:Language Preferred>>
Interpreter required: <<Patient Demographics:Requires Interpreter>>
Indigenous status: <<Indigenous Status>>
Australian South Sea Islander status: <<Australian South Sea Islander status>>
Address: <<Patient Demographics:Full Address>>
Phone (home): <<Patient Demographics:Phone (Home)>>
Phone (work): <<Patient Demographics:Phone (Work)>>
Phone (mobile): <<Patient Demographics:Phone (Mobile)>>
Medicare card number: <<Patient Demographics:Medicare Number>>
DVA card number: <<Patient Demographics:DVA Number>>
Compensable status:  <<Compensable Status>>
Hospital insurance status: <<Hospital Insurance Status>>
Private health insurance fund: <<Patient Demographics:Health Insurance>> =========================================================================================
PATIENT CLINICAL INFORMATION:

Current medications: (please list and provide description, dosage, route, dose quantity, frequency and any additional instructions)
<<Clinical Details:Medication List>>
Warnings / alerts: <<Clinical Details:Warnings>>
Allergies/ adverse reactions: (Please list and including reaction description)
<<Clinical Details:Allergies/Adverse Reactions>>
Recent investigations / test results: (including type, name, date, result status, results)
<<Summary:Investigation Results (Selected)>>
Smoking status:<<Clinical Details:Smoking>>
Alcohol consumption:<<Clinical Details:Alcohol>>
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)
<<Clinical Details:History List>>
Relevant social / family history: (including employment, education, home, finances and activities of daily living)
<<Clinical Details:Social History>>
<<Clinical Details:Family History>>
Special needs and/or psychosocial issues: <<Special needs and/or psychosocial issues>> =========================================================================================
USUAL GP (if different):

Name and Organisation:<<Usual GP Name and Organisation (if different)>>
Contact Details: <<Usual GP Contact Details>> =========================================================================================
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>> =========================================================================================
VERIFICATION:

Doctors Full Name:  <<Doctor:Name>>
Date: <<Miscellaneous:Date>>
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Sent via STS Secure electronic transfer to: HERVEY BAY HOSPITAL QHEALTH 
Form version: 06/17