REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
PAEDIATRIC CLINIC
Template for correspondence about patient with
GENERAL PAEDIATRIC SURGERY AND PAEDIATRIC UROLOGY

SEND TO Professor Deborah Bailey (Clinical Director Paediatric Surgery) 
Outpatient Access and Scheduling Centre
Fax: 07 5687 4497                           OR

Secure Transmission Service via Medical Objects or Healthlink to:
QHEALTH, GOLD COAST HEALTH Outpatients
Outpatient Bookings and Referrals

FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

Dear Professor Bailey

SECTION 1 Patient details

RE: <PtFullName>
DOB: <PtDoB>
AGE: <PtAge>

Gender: <PtSex>
Address: <PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>
Medicare Number*: <PtMCNo> (*Medicare ineligible patients will incur a consultation fee)

Next of Kin/Alternative Contact: <NOKName>
Next of Kin/Alternative Contact Ph: <NOKContact>
Does patient identify as Aboriginal and/or Torres Strait Islander: <Does pt identify as Aboriginal/Torres Strait Islander>
Interpreter required: <Interpreter required>
If yes, specify language: <If yes, specify language>

Mother's name:<Mother's name>
Father's name: <Father's name>
Primary carer's name: <Primary carer's name>
What is their relationship to the child: <What is their relationship to the child>
Please explain to the patient's representative that a parent or guardian who can give consent have to accompany the child to their hospital appointment, unless they are under the care of Department of Child Safety. 

Are there any family court orders in place: <Are there any family court orders in place>
Is there a guardianship order under the Department of Child Safety: <Is there a guardianship order under the DCS>
Was the child born at Gold Coast University Hospital: <Was the child born at Gold Coast Uni Hospital>
SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: <Specify main reason for referral>
Please provide provisional diagnosis (if available): <Provisional diagnosis if available>
Please include any symptoms and date of onset (if known): <Symptoms and date of onset if known>
Paste or type relevant history, clinical examination findings and treatment to date if required
SECTION 3 Mandatory clinical information / Paediatric Concerns

Does the child have pre-existing diagnoses: <Does the child have pre-existing diagnoses>
If yes, please specify: <If yes, specify pre-existing diagnoses>

Please specify the child's weight: <Please specify the child's weight>

BMI included: <BMI included>
If no, please enter: <If no, enter BMI>

Has a diagnosis of constipation been made: <Has a diagnosis of constipation been made>
If yes, consider commencement of aprerients (e.g. Osmolax/Movicol) 

SECTION 4 Investigations

Please include any relevant results or imaging. Films or digital images are preferred if possible and should be brought to the hospital appointment.  

<Ix>
SECTION 5 Duration of referral

Please indicate how long you would like your referral to remain valid: <Duration of referral>

Indefinite referrals do not expire until the patient has been discharged by the hospital service. When referrals expire, there is an expectation that the referring GP or another GP will review the care of the patient. If the patient still requires specialist care, the GP will then be required to submit a new referral for ongoing care. 

SECTION 6 Social factors and impact on the patient and family function

Consider the impact on education; activities of daily life; ability to care for others; personal safety/frailty; other factors. Please paste or type relevant information.

SECTION 7 Medical history including co-morbidities and previous surgical interventions

<PMHAll>
Allergies: <Reactions> 
Current prescribed medications: <CurrentRx>
Immunisation: <Imm>
Relevant family history (allergies, bleeding disorders): <Relevant family history (allergies, blood disorders)>
SMOs/VMOs in this Specialist Service

Professor Deborah Bailey (Clinical Director) | Dr Jennifer Ah Toy | Dr Richard Thompson

 General information about referrals

Queensland Clinical Prioritisation Criteria (CPC) are available for this condition and specialty. These criteria can be viewed by visiting: https://cpc.health.qld.gov.au/

Referral Templates that outline clinical information and investigations required to safely refer your patient into Gold Coast Health can be accessed via: https://www.healthygc.com.au/Health-Care-Professionals/Referral-Templates.aspx

<PtFullName>
DOB: <PtDoB>
Developed in partnership with General Practice Gold Coast, Gold Coast Primary Health Network and Gold Coast Health	2019