Metro North Hospital & Health Service Central Patient Intake
PAEDIATRIC 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 - See below for Norfolk Island Referrers>
For Norfolk Island Referrers <For Norfolk Island Referrers>

Referral date: <TodaysDate>
Length of referral: <Length of referral>
Referrals are shared with other specialists to ensure patients are seen as quickly as possible

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Patient Details   
Re:   <PtFullName>
Patient preferred name: <PtPrefName>
DOB: <PtDoB>     Age: <PtAge>     
Sex: <PtSex>
Medicare Number: <PtMCNo>
Address: <PtAddress>
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 mobile or contact number: <* Parent/Guardian/Agency mobile or contact number>

Postal Address (if different from above):    

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?>

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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 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>
Weight: <Weight>
Does the patient have mobility issues: <Does the patient have mobility issues?>
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>
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 above):<Patient’s Usual G.P. (if different from above)>
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 Paediatric Referral v6.6 BP 30042026
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