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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Specialty referred to:  * Referred to
Specialist requested if different to above: Specialist requested
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

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Patient Details
Re: Patient Demographics.Full Name
DOB: Patient Demographics.DOB  	Age: Patient Demographics.Age	
Sex: Patient Demographics.Gender	Medicare Eligible: Medicare Eligible 
Address: Patient Demographics.Full Address
Medicare Number: Patient Demographics.Medicare Number  Expiry: Patient Demographics.Medicare Expiry Date

Patient Home Phone: Patient Demographics.Phone (Home)
Patient Mobile Phone: Patient Demographics.Phone (Mobile)
Parent/Guardian/Agency name: * Parent/Guardian/Ag
Relationship to patient: Relationship to pati
Parent/Guardian/Agency contact details: * Parent/Guardian/A

Postal Address (if different from above): 

Aboriginal or Torres Strait Islander origin: Aboriginal or Torres
Interpreter required: Interpreter required   If yes ,what is the preferred language: If yes, what is the 
Is child in out of home care? Out of home care
If yes, Child Safety Service Centre name? If yes, child safety

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Reason for referral
* Reason for referra

Please explain if you consider the referral urgent: Please explain if yo

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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/o
Relevant Family History: Relevant Family Hist
What additional documents have been faxed or sent: What additional docu

Relevant Investigations: 
Clinical Details.Result List (Selected)

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Referring Doctor Details
Doctor : Treating Doctor.Name
Provider No.: Treating 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 differen

Is anyone else involved in the care of the patient?  Is anyone else invol

Verification

Signed: Treating Doctor.Name
QCH referral ZM v5.4  181108
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