West Moreton Health 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.  	
Note<Note:> 
SECTION 1 - REFERRAL INFORMATION	

Urgency of referral: <Urgency of referral>
Referral Date: <TodaysDate>
Length of Referral?: <Length of Referral?>
Referral Type: <Referral Type>
Reason for Triage Upgrade request: <Reason for triage upgrade request (type if applicable)?>
Is this a named referral?: <Is this a named referral?>
Speciality Referred to: <Specialty Referred to>
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 (clinical condition e.g., L Knee Pain)>
Have all essential referral criteria (CPC) requirements been addressed? <Have all essential referral criteria (CPC) requirements been addressed? (Please select)>
Reason for Clinical override (if essential criteria unable to be provided)? <Reason for Clinical override (if essential criteria unable to be provided)>
Presence of Clinical Modifiers? <Clinical modifier/s that may impact patient priority (Select all that 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: <Please type all further information regarding referral and clinical override here>

Other referral information	

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

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

Full Name: <PtFullName>	 	
Date of Birth: <PtDoB> 
Age: <PtAge>	
Sex: <PtSex>				

Address: <PtAddress>
Postal Address: <PtPOAddress>
Phone (Home): <PtPhoneH>
Phone (Work): <PtPhoneWk>
Phone (Mobile): <PtPhoneMob>

Medicare Number: <PtMCNo>
Medicare Line number: <PtMCLine>
Medicare expiry: <PtMCExpiry>
DVA Number: <PtDVANo>
DVA Card Type (if applicable): <DVA Card Type (if applicable)>
Pension number: <PtPensionNo>
Private Health Insurance: <PtInsFund>
Private Health Insurance fund number: <PtInsNo>

Aboriginal and Torres Strait Islander status: <Aboriginal and Torres Strait Islander Status>
Ethnicity: <PtEthnicity>	
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: <Does the Patient require an interpreter?>
Preferred Language: <Please type preferred language if not English>

Next of Kin Name: <NOKName>
Next of Kin Phone: <NOKContact>
Next of Kin Address: <Next of Kin Address>
Next of Kin Relationship: <NOKRelation>

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

Child Safety? Caseworker Details (if applicable): <Child Safety? Caseworker contact details (Name, Contact number and address) if applicable>

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

Email address: <PtEmail>

Current and Past Clinical History 	

History of Current Conditions:  <SelectedPMH><ObstetricHx>
Medication List: <SelectedRx>
Allergies/Adverse Events: <Reactions>
Smoking Status: <SmkStatus>
Alcohol Consumption: <AlcHx>

Family and Social Clinical History	

Relevant Social History: <SocialHx>
Relevant Family History: <FamilyHx>

Observations	

Height, Weight & BMI: <Observations>

SECTION 3 - REFERRING DOCTOR DETAILS 	

Doctor: <DrName>						Provider No: <DrProviderNo>
Practice Name: <Practice>
Practice Address: <DrAddress>
Phone: <UsrPhone>						Fax: <UsrFax>
Email: <PracEmail>		Practice HPI-O: <PracticeHPIO>

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

Electronic Verification and Signature	

<DrName>
<DrQualifications>
<DrProviderNo>
<FormattedDate>

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