Metro North Hospital & Health Service Central Patient Intake
PAEDIATRIC REFERRAL FORM
CPI, Aspley Community Health Centre, 776 Zillmere Road, Aspley, Qld, 4034
Phone 1300 364 938    Fax: 1300 364 952

Information and resources are available at :www.health.qld.gov.au/metronorth/refer/
Please direct an acutely unwell patient to the Emergency Department
Secure electronic transfer to: Metro North Central Patient Intake (MQ40290004P)
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Specialty referred to: <<Referral To>>
Referral date: <<Miscellaneous:Date>>
Length of referral: <<Length of referral>>
Referrals are shared with other specialists to ensure patients are seen as quickly as possible

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Patient Details   
Re:   <<Patient Demographics:Full Name>>
Patient preferred name: <<Patient preferred name>>
DOB: <<Patient Demographics:DOB>>     Age: <<Patient Demographics:Age>>     
Sex: <<Patient Demographics:Sex>>
Medicare Number: <<Patient Demographics:Medicare Number>>
Address: <<Patient Demographics:Full Address>>
Patient Home Phone: <<Patient Demographics:Phone (Home)>>
Patient  Mobile Phone: <<Patient Demographics:Phone (Mobile)>>
Parent/Guardian/Agency name: <<Parent/Guardian/Agency name>>
Relationship to patient: <<Relationship to patient>>
Parent/Guardian/Agency mobile or contact number: <<Parent/Guardian/Agency mobile or contact number>>

Postal Address (if different from above):    

Aboriginal or Torres Strait Islander origin: <<Aboriginal or Torres Strait Islander origin>>
Interpreter Required: <<Interpreter required>>      If yes what is the preferred language: <<If yes, what is the preferred language?>>

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Primary Reason for Referral
<<Primary reason for referral>>

Detailed history or comments:
<<Detailed history or other comments>>

Please explain if you consider this referral urgent: 
<<Please explain if you consider this urgent>>

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Patient History
Relevant Medical and Surgical History: 
<<Clinical Details:History List>>
Medication List: <<Clinical Details:Medication List>>
Allergies/ Adverse Events (including medications / food / latex / environment eg grasses): <<Clinical Details:Allergies>>
Weight: <<Clinical Details:Measurements>>
Does the patient have mobility issues: <<Does the patient have mobility issues?>>

Immunisation Status: <<Immunisation Status>>
Social history and/or Psychosocial risk factor(s): <<Social history and/or Psychosocial risk factor(s)>>
Relevant family history:  <<Clinical Details:Family History>>
What additional documents have been faxed or sent: <<What additional documents have been faxed/sent>>
Recent  Investigations: <<Summary:Investigation Results (Selected)>>

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Referring Doctor Details
Doctor : <<Doctor:Name>>
Provider No.: <<Doctor:Provider Number>>
Doctor Address:
 <<Practice:Name>>
 <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>

Patient’s Usual G.P. (if different from above):<<Patient’s Usual G.P. (if different from above)>>
Is anyone else involved in the care of the patient?: <<Is anyone else involved in the care of the patient?>>

Verification

Signed electronically: <<Doctor:Name>>	
MNHHS Paediatric Referral v6.3 MD 07042021
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