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

PATIENT'S DEMOGRAPHIC DETAILS
Title: 
First name: 
Preferred name: 
Middle name: 
Surname: 
Date of birth: 
Residential address: 
Phone – home:                        mobile:                    alternate: 
Medicare number, where eligible:                   Expiry: 
NOK:                                relationship: 
NOK phone:                    alternate: 
Preferred language:                           interpreter required: 
Identifies as Aboriginal and/or Torres Strait Islander: 

PRACTITIONER DETAILS
Full name: 
Full address: 
Phone:                       Fax:                  Email: 
Provider number: 
Date of request: 

RELEVANT CLINICAL INFORMATION
Reason for referral: 

Current symptoms: 
 
STANDARD CLINICAL INFORMATION
Allergies: 

Past Medical history: 

Current medications:

Immunisations:

Investigations: