Sunshine Coast Hospital & Health Service (SCHHS) Central Intake
OUTPATIENT REFERRAL FORM

Secure electronic transfer to: (NQ45600007J)
(Alternatively this referral can be faxed to the Central Booking Office on Fax: 07 5202 0555)

Note the above fax number is for the OUTPATIENT DEPT only and cannot be used for Emergency Department, please refer to Sunshine Coast HealthPathways for further information.

Referring doctor details
Doctor: <DrName>
Provider number: <DrProviderNo>
Practice name: <Practice>
Practice address: <UsrAddress>
Practice phone: <UsrPhone>
Practice fax: <UsrFax>
Practice email: <PracEmail>

Patient details
Re: <PtFirstName> <PtSurname>
DOB: <PtDoB>
Age: <PtAge>
Sex: <PtSex>
Preferred name: <PtPrefName>
IHI: <PtIHI>
Medicare number: <PtMCNo>
DVA number: <PtDVANo>  
Address: <PtStreet>
Postal address (if different from above): <PtPOAddress> <PtPOCity> <PtPOPostcode>
Phone (home): <PtPhoneH>
Phone (work): <PtPhoneWk>
Phone (mobile): <PtPhoneMob>
Email: <PtEmail>

Next of kin: <NOKName>
Next of kin phone: <NOKContact>        <NOKContact2>
Next of kin relationship: <NOKRelation>
Guardian/parent (if different from NOK): <Guardian / parent (if different from NOK)>
Ethnicity: <PtEthnicity>
Antenatal baby's ethnicity: <Antenatal baby's ethnicity>
Interpreter required: <Interpreter required>
Preferred language: <Preferred language>
Does the patient consent to email or SMS contact? <Does the patient consent to email or SMS contact?>
If yes,  have email/mobile details been provided? <If yes, have email / mobile details been provided?>
Able to attend appointment at short notice? <Could patient attend at short notice (mobile req.)?>

Referral Information
Referral date: <TodaysDate>
Specialty referred to: <Specialist/department referring to?>
Referral type: <Referral type>
Does the patient require urgent (within a few days) clinical assessment? <Does the patient need urgent review?>

Reason for referral
Reason for referral (including treatment already trialled): <Reason for referral (include treatment trialled)>

Have the SCHHS pathways and criteria been checked? <Referral criteria checked? (use HealthPathways)>
Reason for criteria override: <Reason for criteria override>
Reason for upgrade request: <Reason for upgrade>
Are you telehealth enabled? <Are you telehealth enabled?>
Is a telehealth consultation clinically appropriate? <Is telehealth clinically appropriate?>

Current and past medical history
Allergies / adverse events: 
<Reactions>

Medication list: 
<SelectedRx>

Active medical and surgical history: 
<PMHActive>

Immunisations: 
<Imm>

Family and social history
Relevant family history: <FamilyHx>
Smoking status: <SmkStatus> <SmkHx>
Alcohol consumption: <AlcHx>

Observations and investigations
Recent observations: 
<Observations>

Relevant investigations: 
<Ix>

I look forward to hearing the outcome of this patient's consultation.

Yours sincerely

<DrName>

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