REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
COVID INJECTABLE THERAPEUTICS CLINIC

SEND TO: Dr Raje
Hospital in the Home

Via Medical Objects to:
QHEALTH GOLD COAST UNIVERSITY HOSPITAL - OUTPATIENT BOOKINGS AND REFERRALS
GQ42150009Z

or

Fax: 07 5687 4497

FROM <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

<<Miscellaneous:Date (long)>>

Dear Dr Raje

SECTION 1 Patient details

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
AGE: <<Patient Demographics:Age>>

Gender: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Full Address>>
Home Ph: <<Patient Demographics:Phone (Home)>>
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>
Medicare Number*: <<Patient Demographics:Medicare Number>> (*Medicare ineligible patients will incur a consultation fee)
Medicare Expiry: <<Patient Demographics:Medicare Expiry Date>>
DVA Number: <<Patient Demographics:DVA Number>>
DVA Expiry: 

Patient email address: <<Patient Demographics:E-mail>>

Next of Kin/Alternative Contact: <<Patient Demographics:Next of Kin>>
Next of Kin/Alternative Contact Ph: <<Patient Demographics:Next of Kin Phone>>
Does patient identify as Aboriginal and/or Torres Strait 
Islander: <<Patient Demographics:ATSI>>
Interpreter required: <<Interpreter required>>
If yes, specify language: <<If yes, specify language>>

SECTION 2 Reason for referral

Date of positive COVID PCR or RAT: <<Date of positive COVID PCR or RAT>>

Rapid Antigen Test: <<Rapid Antigen Test visualised or at home>>

Is the patient symptomatic? <<Is the patient symptomatic?>>  If yes, date of symptoms onset: <<If yes, date of symptoms onset>>

Which medication is patient being referred for: <<Which medication is patient being referred for>>

Which eligibility criteria does this patient meet for this therapy: <<Which patient eligibility criteria is met for this therapy>>

Does the patient have any contraindications for this therapy: <<Does patient have contraindications for this therapy>>

Comorbidities:

Current prescribed medications (must be complete for therapies to be considered):
<<Clinical Details:Medication List>>

eGFR results (must be complete for therapies to be considered): <<eGFR results (must be complete to be considered)>>

eGFR results date (must be complete for therapies to be considered): <<eGFR results date (must be completed)>>
<<Summary:Investigation Results (Selected)>>

Patient vaccination status:  <<Patient vaccination status>>

Past Medical History:

<<Clinical Details:History List>>

Patient Name: <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB (long)>>                                Developed in Partnership by Gold Coast Primary Health Network and Gold Coast Health - 10.07.23