CQHHS SOPD REFERRAL FORM - CQ Wide
Central Queensland Hospital & Health Service (CQHHS)  
Secure electronic transfer for CQ Referral Centre
Medical Objects: <<Send via Medical Objects>>
HealthLink EDI: <<Send via HealthLink>>
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 >>
Referral date: <<Miscellaneous:Date>>
Service provider- Rockhampton: <<Service Provider - Rockhampton>>
Service provider - Gladstone: <<Service Provider - Gladstone>>
Service provider- Emerald: <<Service Provider - Emerald>>
Service provider - Biloela: <<Service Provider - Biloela>>
Service provider - Capricorn Coast: <<Service Provider - Capricorn Coast>> 
Service Provider - Other: <<Service Provider - Other (if not selected above)>>
Priority: <<Priority>>
Public Referral: <<Public Referral>>
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 >>

Have the CQHHS pathways and criteria been checked?

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) >>

CONDITION / SPECIALITY - Specific clinical information - CQ Health Pathways 	
HISTORY AND EXAMINATION: 
Past history list (active): 
<<Clinical Details:History List>>
Medication list: 
<<Clinical Details:Medication List>>
Investigations relevant to this referral (results <3 months old at time of referral) 
<<Summary:Investigation Results (Selected)>>

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

Immunisations
<<Clinical Details:Immunisation List>>

Observations: 
<<Clinical Details:Measurements (Selected)>>

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: <<Patient Demographics:Gender>>
Indigenous Status: <<Patient Demographics:ATSI>>
Occupation: <<Patient Demographics:Occupation>>

Patient Contact Details
Residential: <<Patient Demographics:Full Address>>
Postal: (if different from above): <<Patient Demographics:Full 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>>
Guardian/parent (if different from NOK): <<Parent/guardian (if different from NOK)>>

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 patient's consultation. 
Yours Sincerely, 
<<Doctor:Name>>