Metro North Hospital & Health Service Central Patient Intake
OUTPATIENT 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>>
Location: REDCLIFFE HOSPITAL
Referral date: <<Miscellaneous:Date>>
Length of referral: <<Length of referral>>

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Patient Details
Re:   <<Patient Demographics:Full Name>>
Preferred name: <<Patient preferred name>>
DOB: <<Patient Demographics:DOB>>     Age: <<Patient Demographics:Age>>     Sex: <<Patient Demographics:Sex>>
Address:   
<<Patient Demographics:Full Address>>

Postal Address (if different from above):    
Phone (Home): <<Patient Demographics:Phone (Home)>>
Phone (Work): <<Patient Demographics:Phone (Work)>>
Phone (Mobile): <<Patient Demographics:Phone (Mobile)>>

Alternate contact person: <<Alternate contact person>>
Relationship to Patient:: <<Relationship to Patient>>
Alternate contact person phone number: <<Alternate contact person phone number>>
Aboriginal or Torres Strait Islander origin: <<Aboriginal or Torres Strait Islander origin>>
Interpreter Required: <<Interpreter required>>      Preferred Language: <<If yes, what is the preferred language >>
Medicare Number: <<Patient Demographics:Medicare Number>>
DVA Number: <<Patient Demographics:DVA Number>>      DVA Card Type: <<DVA Card Type>>
Occupation: <<Patient Demographics:Occupation>>
Health Insurance Provider: <<Patient Demographics:Health Insurance>>
Workers Compensation claim details <<Workers compensation claim details:>>

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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 referral 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>>
Relevant Social History:  <<Clinical Details:Social History>>
Relevant Family History:  <<Clinical Details:Family History>>
Smoking Status: <<Clinical Details:Smoking>>
Alcohol Consumption: <<Clinical Details:Alcohol>>
Please provide the Clinical Frailty Score: <<Please provide the Frailty Score>>
Clinical Frailty Tool: <<Clinical Frailty Tool>>
Weight: <<Clinical Details:Measurements>>
Does the patient have mobility issues: <<Does the patient have mobility issues?>>

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 referrer): <<Patient’s Usual G.P. (if different from referrer):>>
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 Redcliffe Adult Referral v6.3 MD 07042021
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