West Moreton Hospital Central Referrals Hub 
SPECIALIST OUTPATIENT REFERRAL FORM
Ipswich Hospital Outpatient Department (IQ43050005G) 
Urgent Fax line 3413 7277 
Routine Fax 3810 1438

WMH encourages the utilisation of GPSR software to submit referrals and referral management. Please contact WM-SmartReferrals@Health.qld.gov.au	

If your patient is:
•	An Emergency transfer to the emergency department and additional information 		has been requested, fax directly to 38101764.
•	For the Medical Rapid Access Clinic (MRAC) - Call 34135868.
•	For the Preventative Integrated Care Service (PICS) - Call the CNC triage line 			on 0409594866.
•	For Hospital in the Home - Call the intake line on 0418177831.

General information about referrals

For further information regarding Clinical Prioritisation Criteria (CPC) and Referral Guidelines for medical conditions suitable for referral to WMH Specialist Outpatient Clinics please visit:

 https://westmoreton.communityhealthpathways.org/ (Username: wmuser & Password: wmpassword) or https://www.westmoreton.health.qld.gov.au/refer 

CPC and Guidelines also include information about specific conditions that should be considered 'emergency referrals' and be sent directly to the Emergency Department and those that are considered 'out-of-scope' for public outpatient services.  	 <<Please note>>

SECTION 1 - REFERRAL INFORMATION	

Urgency of referral: <<Urgency of Referral>>
Referral Date: <<Miscellaneous:Date>>	
Length of Referral?:<<Length of Referral>>
Referral Type:<<Referral Type>>
Reason for Triage Upgrade request: <<Reason for Triage Upgrade request>>
Is this a named referral? <<Is this a named referral?>>
Speciality Referred to?<<Speciality referred to? (please select)>>
(Antenatal Only) Is this GP Shared Care? <<(Antenatal Only) Is this GP Shared Care?>>

	

Reason for Referral (clinical condition e.g., L Knee Pain): <<Reason for Referral (condition e.g., L Knee Pain)>> 
Have all essential referral criteria (CPC) requirements been addressed?<<All essential referral criteria addressed (select)?>>
Reason for Clinical override (if essential criteria unable to be provided)?<<Reason for Clinical Override? (please select)>>
Presence of Clinical Modifiers?<<Clinical modifier/s (remove all that do not apply)>>
Please type all further information regarding referral and clinical override here (Please include ALL standard, essential referral information from https://www.westmoreton.health.qld.gov.au/refer: <<Type all further info re referral and clinical override>>

Other referral information	

Could Case conference be considered for Complex and Palliative Chronic disease patients?<<Could case conference be considered?>>

SECTION 2 - PATIENT DETAILS      Next of kin must be completed for children under the age of 18	

Full name:<<Patient Demographics:Full Name>>		Gender: <<Patient Demographics:Gender>>
Date of Birth: <<Patient Demographics:DOB (long)>>		Age: <<Patient Demographics:Age>>

Address:<<Patient Demographics:Full Address>>
Postal Address:<<Patient Demographics:Full Address Postal>>
Phone (Home):<<Patient Demographics:Phone (Home)>>
Phone (Work):<<Patient Demographics:Phone (Work)>>
Phone (Mobile):<<Patient Demographics:Phone (Mobile)>>

Medicare Number:<<Patient Demographics:Medicare Number>>   
Medicare Line Number: <<Medicare Line Number >>
Medicare expiry:<<Patient Demographics:Medicare Expiry Date>>
DVA Number (if applicable):<<Patient Demographics:DVA Number>>
DVA Card Type (if applicable): <<DVA Card Type (if applicable)>>
Pension number:<<Patient Demographics:Pension Number>>
Private Health Insurance:<<Patient Demographics:Health Insurance>>
Private Health Fund Number: <<Private Health Fund Number>>

Aboriginal and Torres Strait Islander status?<<Patient Demographics:ATSI>>
Ethnicity:<<Patient Demographics:Ethnicity>>
Is the patient of refugee background?<<Is the patient of refugee background?>>
If yes, please provide relevant details: <<If yes, please provide relevant refugee details>>
Interpreter Required:<<Patient Demographics:Requires Interpreter>> 
Preferred Language:<<Patient Demographics:Language Preferred>>

Next of Kin Name:<<Patient Demographics:Next of Kin>>
Next of Kin Phone:<<Patient Demographics:Next of Kin Phone>>
Next of Kin Address: <<Patient Demographics:Next of Kin Address>>
Next of Kin Relationship:<<Patient Demographics:Next of Kin Relationship>>

	

If the client is a paediatric patient, are they under the care of the Department of Child Safety?<<Is patient under care of Depart. of Child Safety?>>

Child Saftey? Caseworker details (if applicable): <<Child Saftey? Caseworker details (if applicable)>>

Does the patient consent to email or SMS Contact from West Moreton Health?<<Does patient consent to contact?>>

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

Current and Past Clinical History	

History of Current Conditions:<<Clinical Details:History List>>
Medication List:<<Clinical Details:Medication List>>
Allergies/Adverse Events:<<Clinical Details:Allergies/Adverse Reactions>>
Smoking Status:<<Clinical Details:Smoking>>
Alcohol Consumption:<<Clinical Details:Alcohol>>

Family and Social Clinical History	

Relevant Social History:<<Clinical Details:Social History>>
Relevant Family History:<<Clinical Details:Family History>>

Observations	

Height: <<Clinical Details:Measurements (Selected)>>
Weight: <<Clinical Details:Measurements (Selected)>>
BMI: <<Clinical Details:Measurements (Selected)>>

SECTION 3 - REFERRING DOCTOR DETAILS	

Doctor:<<Doctor:Name>>	Provider No:<<Doctor:Provider Number>>
Practice name:<<Practice/Location:Name>>
Practice Address:<<Practice/Location:Address>>
Phone:<<Practice/Location:Phone>>	Fax:<<Practice/Location:Fax>>
Email:<<Practice/Location:E-mail>>	Practice HPI-O:<<Practice/Location:HPI-O>>

Are any other practitioner's involved in the care of the patient? <<Other Practitioner's involved care of patient>>
Patient's usual GP/other practitioner (if different from referrer):<<Patient's usual GP/other >>

Electronic Verification and Signature	

<<Doctor:Name>>
<<Doctor:Qualifications>>
<<Doctor:Provider Number>>
<<Miscellaneous:Date (short)>>

I look forward to hearing the outcome of this patient's consultation.