Hospital Administration Use Only: Affix patient label here

WBHHS  OUTPATIENT REFERRAL FORM
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PATIENT DETAILS:
Surname: 
Given name: 
DOB: 
Sex: 
Preferred language: 
Interpreter required: 
Indigenous status: 
Australian South Sea Islander status: 
Address: 
Phone (home): 
Phone (work): 
Phone (mobile): 
Medicare card number: 
DVA card number: 
Compensable status: 
Hospital insurance status: 
Private health insurance fund: ====================================================================
REFERRAL TO:
Organisation (indicate [X] where relevant):
[ ] Bundaberg Hospital (Medical Objects: XB4670000X6)
[ ] Hervey Bay Hospital (Medical Objects: XH46550004U)
[ ] Maryborough Hospital (Medical Objects: XM4650000FF)
Clinic referred to: 
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REFERRAL FROM: 
Referring clinician: 
Organisation: 
Address: 
Phone: 
Email: 
Fax: 
Provider number: 
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REFERRAL: 
Date of referral: 
Referral validity duration: 
Reason for referral:

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PATIENT CLINICAL INFORMATION:
Current medications: (please list and provide description, dosage, route, dose quantity, frequency and any additional instructions)

Warnings / alerts: 
Allergies/ adverse reactions: (Please list any including reaction description)

Recent investigations / test results: (including type, name, date, result status, results)

Smoking status: 
Alcohol consumption: 
Existence of Advanced Health Directive: ====================================================================
PATIENT CLINICAL HISTORY:
BMI: 
Patient history: 

Special needs and/or psychosocial issues: ====================================================================
USUAL GP (if different):
Name and Organisation: 
Contact Details: 
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ALTERNATE CONTACT(S):
Alternate Contact name: 
Relationship to patient: 
Alternate Contact contact details: ====================================================================
VERIFICATION:
Doctors Full Name: 
Date: 
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template version: 0621RTF, maintained by CQ,WB,SC PHN