Metro North Hospital & Health Service Central Patient Intake
OUTPATIENT REFERRAL FORM
CPI, Aspley Community Health Centre, 776 Zillmere Road, Aspley, Qld, 4034
Phone 1300 364 938    Fax: 1300 364 952

GP Smart Referrals is the preferred referral method https://practicesupport.org.au/toolbox/referrral-pathways/gp-smart-referrals

Information and resources are available at: www.health.qld.gov.au/metronorth/refer/
Please direct an acutely unwell patient to the Emergency Department

Secure electronic transfer to: Metro North Central Patient Intake 
Medical Objects: (MQ40290004P)                 Health Link EDI: qldmnhhs 
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Specialty referred to: <Referral To>
Location: Community and Oral Health Directorate (COHD) 
Referral date: <TodaysDate>
Length of referral: <Length of referral>

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Patient Details
Re:   <PtFullName>
Preferred name: <PtPrefName>
DOB: <PtDoB>     Age: <PtAge>     Sex: <PtSex>
Address:   
<PtAddress>

Postal Address (if different from above):    
Phone (Home): <PtPhoneH>
Phone (Work): <PtPhoneWk>
Phone (Mobile): <PtPhoneMob>
Alternate contact person: <Alternate contact person>
Relationship to Patient: <Relationship to Patient>
Alternate contact person phone number: <Alternate contact person phone number>

Aboriginal or Torres Strait Islander origin: <Aboriginal or Torres Strait Islander origin>
Interpreter Required: <Interpreter required>      Preferred Language: <If yes, what is the preferred language>
Medicare Number: <PtMCNo>
DVA Number: <PtDVANo>      DVA Card Type: <DVA Card Type>
Occupation: <PtOccupation>
Health Insurance Provider: <PtHealthIns>
Workers Compensation claim details: <Workers compensation claim details>

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Primary Reason for Referral
<Primary reason for referral>

Detailed history or comments:
<Detailed history or other comments>

Please explain if you consider this referral urgent: <Please explain if you consider this referral urgent>

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Patient History
Relevant Medical and Surgical History: 
<SelectedPMH>
Medication List: <SelectedRx>
Allergies/ Adverse Events (including medications / food / latex / environment eg grasses): <Reactions>
Relevant Social History:  <SocialHx>
Relevant Family History:  <FamilyHx>
Smoking Status: <SmkStatus>
Alcohol Consumption: <AlcHx>
Please provide the Clinical Frailty Score: <Please provide the Clinical Frailty Score>
Clinical Frailty Tool: <Clinical Frailty Tool>
Weight: <Weight>
Does the patient have mobility issues: <Does the patient have mobility issues?>

What additional documents have been faxed or sent: <What additional documents have been faxed/sent>
Recent  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) <Patient’s Usual G.P. (if different from referrer)>
Is anyone else involved in the care of the patient?: <Is anyone else involved in the care of the patient?>

Verification

Signed electronically: <DrName>	
MNHHS COHD Adult Referral v6.6 BP 30042026 ==============================================================================