Re: <PtFirstName> <PtSurname>   DOB: <PtDoB>

Wide Bay Hospital & Health Service
Integrated Care (HiTH/Virtual Ward) Referral 
Send via secure messaging:
Medical Objects: WQ4655000XK
Healthlink: qldwbcov

PATIENT'S DEMOGRAPHIC DETAILS
Title: <PtTitle>
First name: <PtFirstName>
Preferred name: <PtPrefName>
Middle name: <PtMidName>
Surname: <PtSurname>
Date of birth: <PtDoB>
Residential address: <PtAddress>
Phone – home: <PtPhoneH>   mobile: <PtPhoneMob>       alternate: 
Medicare number, where eligible: <PtMCNo> / <PtMCLine> Expiry: <PtMCExpiry>
Name of the parent or caregiver, NOK: 
NOK: <NOKName>      relationship: <NOKRelation>
NOK phone: <NOKContact>      alternate: <NOKContact2>
Preferred language: <Preferred language>   interpreter required: <Interpreter required>
Identifies as Aboriginal and/or Torres Strait Islander: <Aboriginal and/or Torres Strait Islander Status>

PRACTITIONER DETAILS
Full name: <DrName>
Full address: <DrAddress>
Phone: <DrPhone>   Fax: <DrFax>   Email: <DrEmail>
Provider number: <DrProviderNo>
Date of request: <TodaysDate>

RELEVANT CLINICAL INFORMATION
Reason for referral: <Reason for referral>
Current symptoms: <Current symptoms>

STANDARD CLINICAL INFORMATION
Allergies:
<Reactions>

Past Medical history: 
<SelectedPMH>

Current medications:
<SelectedRx>

Immunisations:
<Imm>

Investigations:
<Ix>