Sunshine Coast Hospital and Health Service
(NQ45600007J)
 Nurse Navigator Generalist Referral Form
(MD V1.0, December 2020)

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Date of Referral: <<Miscellaneous:Date>>

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PATIENT DETAILS

RE: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Preferred name: 
Date of birth: <<Patient Demographics:DOB>>
Gender: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Address>>
Phone numbers: Home <<Patient Demographics:Phone (Home)>> Mobile <<Patient Demographics:Phone (Mobile)>> Work  <<Patient Demographics:Phone (Work)>>
Email: <<Patient Demographics:E-mail>>
Marital status: <<Patient Demographics:Marital Status>>
Aboriginal or Torres Strait Islander origin: <<Aboriginal or Torres Strait Islander?>>
Ethnicity: <<Patient Demographics:Ethnicity>>
Language spoken (if not English): <<Language spoken (if not English)>>
Is an interpreter required: <<Is an interpreter required?>>

Emergency contact details: 
Name: <<Patient Demographics:Emergency Contact>>
Relationship: <<Patient Demographics:Emergency Contact Relationship>>
Phone number: <<Patient Demographics:Emergency Contact Phone>>

Patient consent: <<Is the patient aware of this referral?>> 
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PRIMARY REASON FOR REFERRAL – 
Tick all that apply

Chronicity: 		
<<Select referral criteria- Chronicity>>

Complexity: 
<<Select referral criteria - Complexity1>>
<<Select referral criteria - Complexity2>>
<<Select referral criteria- Complexity3>>

Fragility and/or Intensity:	
<<Select referral criteria - Fragility and/or Intensity1>>
<<Select referral criteria - Fragility and/or Intensity2>> 

Additonal comments: 
<<Additional comments>>
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MEDICAL HISTORY

Active Medical History: 
<<Clinical Details:History List>>

Inactive Medical History:
<<Clinical Details:History List>>

Medications:
<<Clinical Details:Medication List>>

Main purpose for referral is for patient to receive:
<<Main purpose of referral is for patient to receive:>>   

Medical concerns or planned interventions: 
<<Medical concerns or planned interventions>>

Additonal referral information: (e.g. medical/family needs, ACAT assessed):
 <<Additional referral information>>

Please attach applicable documents:
 <<Please attach any applicable documents>>   
 
Current inpatient - estimated discharge date: <<If current in-patient, estimated date of discharge>> Hospital: <<If current in-patient, name of hospital>> 

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REFERRING DOCTOR DETAILS

Name: <<Doctor:Name>>
Qualifications: <<Doctor:Qualifications>>
Provider No: <<Doctor:Provider Number>>
Practice Name: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>

Please list other professionals involved in care of this patient: <<Other health professionals involved care>>

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VERIFICATION

Electronically Signed: <<Doctor:Name>>
<<Miscellaneous:Date (short)>>

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SUBMITTING YOUR REFERRAL

Secure messaging via Medical Objects: Qhealth, Sunshine Coast Ambulatory Care Centre  (NQ45600007J)

If unable to send electronically, fax: 07 5205 0555 

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