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:   <TodaysDate>
Length of referral:   <* Length of referral>
Telehealth Referral: <Is this a Telehealth Referral>

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Patient Details
Re: <PtFullName>
DOB: <PtDoB>  	Age: <PtAge>   	
Sex: <PtSex>	Medicare Eligible: <Medicare Eligible>

Medicare Number:<PtMCNo>  	Expiry: <PtMCExpiry>         

Address:
<PtAddress>
Postal Address (if different from above): 

Patient Home Phone: <PtPhoneH>
Patient Mobile Phone: <PtPhoneMob>

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? <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
<SelectedPMH>

Current medications: <SelectedRx>

Allergies: <Reactions> 

Immunisation status: <Immunisation status> 

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

Relevant Investigations: 
<Ix>

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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): <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: <DrName>
QCH referral v5.4 BP 181109
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