Children's Health Queensland 
Hospital and Health Service
	
	Queensland Children’s Hospital
501 Stanley Street,South Brisbane Qld 4101
Hospital switchboard: (07) 3068 1111
Medical Objects ID: (RQ402900084)
Referral Fax: 1300 407 281	

Information and resources are available at www.childrens.health.qld.gov.au/referapatient
Please direct an acutely unwell child to the Emergency Department

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Referred to: <<Referred to:>> 
Specialist requested if different to above: <<Specialist requested if different to above>>
Referrals are shared with other specialists to ensure patients are seen as quickly as possible.
Referral date:   <<Miscellaneous:Date>>
Length of referral:   <<* Length of referral>>
Telehealth Referral: <<Is this a Telehealth Referral>>

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Patient Details
Re: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>  	Age: <<Patient Demographics:Age>>   	
Sex: <<Patient Demographics:Sex>>	Medicare Eligible: <<Medicare Eligible >>

Medicare Number:<<Patient Demographics:Medicare Number>>  Expiry: <<Patient Demographics:Medicare Expiry Date>>   

Address: <<Patient Demographics:Full Address>>
Postal Address (if different from above): <<Postal Address (if different from above):>>

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 contact details: <<* Parent/Guardian/Agency contact details>>

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? >>
Is child in out of home care? <<Out of home care?:>> If yes, Child Safety Service Centre name? <<If yes, Child Safety Service Centre name?:>>  
 
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Reason for referral
<<* Reason for referral>>

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

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Past History

Current medications: <<Clinical Details:Medication List>>

Allergies: <<Clinical Details:Allergies>> 

Immunisation status: <<Immunisation status>> 
Social history and/or Psychosocial risk factor(s): <<Social history and/or Psychosocial risk factor(s)>>
Relevant Family History: <<Relevant Family History>>
What additional documents have been faxed or sent: <<What additional documents have been faxed/sent?>>

Relevant 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): <<Usual GP if different from referrer>>

Is anyone else involved in the care of the patient?  <<Is anyone else involved in the care of this patient?>>

Verification

Signed: <<Doctor:Name>>
QCH Referral v6.4. MD 200401
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