Re: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>  DOB: <<Patient Demographics:DOB>>

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

PATIENT'S DEMOGRAPHIC DETAILS
Title: <<Patient Demographics:Title>>
First name: <<Patient Demographics:First Name>>
Preferred name: 
Middle name: <<Patient Demographics:Middle Name>>
Surname: <<Patient Demographics:Surname>>
Date of birth: <<Patient Demographics:DOB>>
Residential address: <<Patient Demographics:Address>>
Phone – home: <<Patient Demographics:Phone (Home)>>  mobile: <<Patient Demographics:Phone (Mobile)>>  alternate: 
Medicare number, where eligible: <<Patient Demographics:Medicare Number>>   Expiry: <<Patient Demographics:Medicare Expiry Date>>
NOK: <<Patient Demographics:Next of Kin>>         relationship: <<Patient Demographics:Next of Kin Relationship>>
NOK phone: <<Patient Demographics:Next of Kin Phone>>          alternate: 
Preferred language: <<Patient Demographics:Language Preferred>>  interpreter required: <<Patient Demographics:Requires Interpreter>>
Identifies as Aboriginal and/or Torres Strait Islander: <<Patient Demographics:ATSI>>

PRACTITIONER DETAILS
Full name: <<Doctor:Name>>
Full address: <<Doctor:Address>>
Phone: <<Doctor:Phone>>  Fax: <<Doctor:Fax>>  Email: <<Doctor:E-mail>>
Provider number: <<Doctor:Provider Number>>
Date of request: <<Miscellaneous:Date (short)>>

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

Current symptoms: <<Current symptoms>>
 
STANDARD CLINICAL INFORMATION
Allergies: 
<<Clinical Details:Allergies/Adverse Reactions>>

Past Medical history: 
<<Clinical Details:History List>>

Current medications:
<<Clinical Details:Medication List>>

Immunisations:
<<Clinical Details:Immunisation List>>

Investigations:
<<Summary:Investigation Results (Selected)>>