GP Referral to Sunshine Coast Hospital and Health Service 	

FACSIMILE

	

TO:	Fax:	07 5202 0555		FROM:	Fax:	<UsrFax>	
							
	Name:	REFERRALS CENTRE
			Phone:	<UsrPhone>	
							
	Organisation:	Ambulatory Care Centre, Sunshine Coast University Hospital			Practice Name:	<Practice>
<UsrAddress>	
							
	Date:	<TodaysDate>					
CONFIDENTIAL COMMUNICATION
SUBJECT:  	REFERRAL INFORMATION - UNABLE TO BE SENT ELECTRONICALLY	

Patient Name: 	<PtFullName>           Date original referral sent: <Date original referral sent?> 

DOB: 	<PtDoB>		                       Speciality/Clinic referred to:  <Specialty/clinic referred to?>

Address:  <PtAddress>

Please indicate which option applies: 

□ 	I have sent a new e-Referral and was unable to attach this document. Please attach to e-Referral.
 
□ 	I have previously HAD A REFERRAL ACCEPTED and want to provide updated information or results.*

*Please send all clinical information electronically wherever possible

DOCTOR STAMP HERE

Referring GP:  <DrName>

Signature: _________________________________