Metro North Hospital & Health Service Central Patient Intake
PALLIATIVE CARE REFERRAL FORM

MNHHS Central Patient Intake,
Aspley Community Health Centre,
776 Zillmere Road, Aspley, Qld, 4034.
Phone 1300 364 938 Fax: 1300 364 952
Secure electronic transfer to Metro North Central Patient Intake (MQ40290004P)

Information and resources are available at :www.health.qld.gov.au/metronorth/refer/
==============================================================================
Specialty referred to: <Specialty referred to: >
Type of service:  <Type of service:>
Referral date: <TodaysDate>

An assessment and triage process by the palliative care team will aim to develop a management plan involving services that are appropriate to the patient’s circumstance. Incomplete referrals or absence of essential information will delay the process.
If the matter is URGENT or OUTSIDE BUSINESS HOURS, please telephone switchboard and ask for
the Palliative Care Doctor on call.

==============================================================================
Patient Details
Re: <PtFullName>
Patient preferred name: <PtPrefName>
Sex: <PtSex>
DOB: <PtDoB>	Age: <PtAge>
Medicare Number: <PtMCNo>   Exp:<PtMCExpiry>
Address: <PtAddress>		Phone (hm): <PtPhoneH>    Phone (mob): <PtPhoneMob>
Preferred mailing address: <Preferred mailing address: (if different)>	Lives alone: <Lives alone>
Aboriginal or Torres Strait Islander origin: <Aboriginal or Torres Strait Islander origin>
Interpreter required: <Interpreter required:>	Language: <If yes, what is the preferred language>

Alternative contact name: <Alternative contact name:>
Alternative contact address: <Alternative contact address>
Alternative contact phone: <Alternative contact phone>
Relationship to patient: <Alternative contact relationship>	Alternative contact to be present at assessment: <Alternative contact to be present at assessment>

==============================================================================
Reason for referral
<Reason for referral>

Life limiting illness
Primary diagnosis (inc date): <Primary diagnosis (inc date):>
Significant Comorbidities: <Significant Comorbidities>
Detailed history of comments: <Detailed history of comments:>
Location of patient: <Location of patient:>
Ideal response time: <Ideal response time:>
Name of the consultant case discussed with: <Name of the consultant case discussed with>

==============================================================================
Past History

Relevant Medical and Surgical History: <SelectedPMH>

Current medications: <SelectedRx>
Relevant Medical and Surgical History: <PMHAll>

Allergies: <Reactions>

Please provide the Clinical Frailty Score: <Please provide the Clinical Frailty Score>
Clinical Frailty Tool: <Clinical Frailty Tool>

Weight: <Weight>
Does the patient have mobility issues: <Does the patient have mobility issues ?>

Relevant Investigations: <Ix>

Details of additional documents faxed eg (EPOA)? <Details of additional documents faxed eg (EPOA)?>

==============================================================================
Referring Doctor Details	
Doctor: <DrName>
Provider No. <DrProviderNo>
Doctor Address:
<Practice>
 <UsrAddress> 
Phone: <UsrPhone>
Fax: <UsrFax>

Patient’s Usual G.P. (if different from referrer): <Patient’s Usual G.P. (if different from referrer)>

Verification
Signed: <DrName>	
MNHHS Palliative Care Referral v6.2  BP 190701
==============================================================================
Metro North Palliative Care Contact Details

Redcliffe / Caboolture / Kilcoy Palliative Care Service
	Phone: 07 3883 7777  (Urgent medical referrals – ask for PCU Dr on call). 	Fax: 1300 364 952

The Prince Charles Hospital
	Phone: 07 3139 4000  (Urgent medical referrals – ask for PCU Dr on call) 	Fax: 1300 364 952

Royal Brisbane and Women’s Hospital
Phone: 07 3646 8111 Inpatient referrals only(Urgent medical referrals – ask for PCU Dr on call)

Domiciliary Palliative Care
	Phone: 1300 658 252 (CRU enquiries)
	Fax: 1300 364 952 (CPI Fax) or Fax: 3049 1260 (weekend domiciliary referrals only)

For Services outside of Metro North
Palliative Care Helpline 	Phone: 1800 772 273	Paediatric Palliative Care Service (under 16) 	Phone: 1800 249 648