CANCER CARE SERVICE

REFERRAL

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Wide Bay Hospital and Health Service
CANCER CARE SERVICE
Referral Form
Private patients will be Bulk Billed
Hervey Bay	Maryborough Bundaberg	........................................................................	(Affix identification label here)

URN:

Family name: Given name(s): Address:
Date of birth:	Sex:	M	F	I	
Speciality: Specialist Palliative Care in Aged Care (SPACE)
Referring Dr:	Contact Number:
Address:
Reason for referral:		

Is patient aware of diagnosis?          Yes        No
                                                               
Relevant clinical history /clinical notes: Including all recent tests/investigations (providers) and comorbidities

Relevant medications & allergies:

	
Patient Declaration: (Bulk Billed OUTPATIENT Referrals only)	
I have been advised of my option to be treated as a private patient and about associated financial consequences and	
subsequently have chosen to be treated as a private patient. I am aware that I can be seen as a public patient but I have	
chosen to access this service as a private patient. I also give consent for the release of my health information for ongoing care.	
Medicare Number: ..............................................................................................................................	Expiry Date: .................................................................................................	
Patient’s signature: .........................................................................................................................	Date: .................................................................................................	
Doctor’s Use Only (if patient is unavailable to sign declaration)	
I confirm that I have advised the patient of the above options and obtained their verbal consent to sign on their behalf	
Doctor’s signature: .........................................................................................................................	Date: .................................................................................................	
Referring Consultant:	Signature: .................................................................................................
Requesting Medical Officer:	Signature: .................................................................................................
Pager:	Provider No.:	Date:	
•	Incomplete forms will not be accepted, ensure all sections are completed.
•	Inpatient referrals: Oncology Consultant or Register/PHO must be contacted prior to sending referral.
Send Referral to:	Email:     WBHHS-Bundaberg-RaSS@health.qld.gov.au	
Office Use Only - Cancer Care Service Referral Triage	
Dr / Clinic: ...............................................................................................................................	Appointment Date & Time: ........................................................................................	

00062:CC6   v6.00   08/2017

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