Hospital Administration Use Only: Affix patient label here

WBHHS  OUTPATIENT REFERRAL FORM
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PATIENT DETAILS:
Re: <<Patient Demographics:Full Name>>
Surname: <<Patient Demographics:Surname>>
Given name: <<Patient Demographics:First Name>>
DOB: <<Patient Demographics:DOB>>
Sex: <<Patient Demographics:Gender>>
Preferred language: <<Patient Demographics:Language Preferred>>
Interpreter required: <<Patient Demographics:Requires Interpreter>>
Indigenous status: <<Indigenous Status>>
Australian South Sea Islander status: <<Australian South Sea Islander status>>
Address: <<Patient Demographics:Full Address>>
Phone (home): <<Patient Demographics:Phone (Home)>>
Phone (work): <<Patient Demographics:Phone (Work)>>
Phone (mobile): <<Patient Demographics:Phone (Mobile)>>
Medicare card number: <<Patient Demographics:Medicare Number>>
DVA card number: <<Patient Demographics:DVA Number>>
Compensable status: <<Compensable Status>>
Hospital insurance status: <<Hospital Insurance Status>>
Private health insurance fund: <<Patient Demographics:Health Insurance>>
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REFERRAL TO:
Organisation: <<Organisation referring to>>
Clinic referred to: <<Clinic referred to (Bundaberg)>> <<Clinic referred to (Hervey Bay)>> <<Clinic referred to (Maryborough)>>
Referral to (type name here if not listed above): <<Referral to (type name here if not listed above)>>
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REFERRAL FROM: 
Referring clinician: <<Doctor:Name>>
Organisation: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Email: <<Doctor:E-mail>>
Fax: <<Doctor:Fax>>
Provider number: <<Doctor:Provider Number>>
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REFERRAL: 
Date of referral: <<Miscellaneous:Date (short)>>
Referral validity duration: <<Referral Validity Duration>>
Reason for referral: <<Reason for Referral>>
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PATIENT CLINICAL INFORMATION:
Current medications: (please list and provide description, dosage, route, dose quantity, frequency and any additional instructions)
<<Clinical Details:Medication List>>
Warnings / alerts: <<Clinical Details:Warnings>>
Allergies/ adverse reactions: (Please list any including reaction description)
<<Clinical Details:Allergies/Adverse Reactions>>
Recent investigations / test results: (including type, name, date, result status, results)
<<Summary:Investigation Results (Selected)>>
Smoking status: <<Clinical Details:Smoking>>
Alcohol consumption: <<Clinical Details:Alcohol>>
Existence of Advanced Health Directive: <<Existence of Advanced Health Directive>>
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PATIENT CLINICAL HISTORY:
BMI: <<Patient BMI>>
Patient history: 
<<Clinical Details:History List>>
Special needs and/or psychosocial issues: <<Special needs and/or psychosocial issues>> ====================================================================
USUAL GP (if different):
Name and Organisation: <<Usual GP Name and Organisation (if different)>>
Contact Details: <<Usual GP Contact Details>> ====================================================================
ALTERNATE CONTACT(S):
Alternate Contact name: <<Alternate contact name (first name,family name)>>
Relationship to patient: <<Relationship to patient>>
Alternate Contact contact details: <<Alternate Contact contact details>> ====================================================================
VERIFICATION:
Doctors Full Name: <<Doctor:Name>>
Date: <<Miscellaneous:Date>>
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template version: 0921MD, maintained by CQ,WB,SC PHN