GP Referral to Sunshine Coast Hospital and Health Service 	

FACSIMILE

	

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

Patient Name: <<Patient Demographics:Full Name>>           Date original referral sent: <<Date Original Referral Sent>> 

DOB: <<Patient Demographics:DOB (long)>>		                       Speciality/Clinic referred to: <<Specialty/Clinic referred to?>>
Address:<<Patient Demographics:Full Address>>

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: <<Doctor:Name>>

Signature: _________________________________