Metro North Hospital & Health Service Virtual Ward 
 GP Referral Form
Located at RBWH, Butterfield St, Herston 4029
Phone 07 3074 2109 (Between 0800-1700) 

 Please call the VW SMO/Consultant to confirm acceptance of care and complete the following form

Please note we are UNABLE to accept referrals WITHOUT PRIOR discussion with a VW SMO or representative.

Referral date: <TodaysDate>
Accepting VW Clinician: <Accepting VW Clinician>
Secure electronic transfer to: Metro North Central Patient Intake (MQ4006000A4)
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Patient details

Patient name:  <PtFullName>
Preferred name:  <PtPrefName>
DOB: <PtDoB>
Age: <PtAge> 
Sex: <PtSex>
Medicare Number: <PtMCNo> <PtMCLine> 
DVA Number: <PtDVANo> <PtDVACard>
Health Insurance Provider: <PtInsNo> <PtInsFund>

Residential Address:   <PtAddress>

Phone (Home): <PtPhoneH>
Phone (Mobile):  <PtPhoneMob>

Alternate contact person/carer:  <NOKName>
Relationship to patient:  <NOKRelation>
Alternate contact person phone number:  <NOKContact>

Does your patient identify as Aboriginal or Torres Strait Islander? <Does your patient identify as Aboriginal or Torres Strait Islander?>

Does the patient consent to be contacted and admitted to the Virtual ward? <Does the patient consent to be contacted and admitted to the Virtual ward?>
Does the patient have any significant hearing issues? <Does the patient have any significant hearing issues?>
Does the patient have any significant vision issues? <Does the patient have any significant vision issues?>
Does the patient have any significant cognitive impairment? <Does the patient have any significant cognitive impairment?>
Is an interpreter required? <Is an interpreter required?>

If you answered “Yes” to any of the above questions, please provide further details.

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Primary Reason for Referral: 

Relevant history and background:

Proposed management plan for the Virtual ward: 

Past Medical and Surgical History: <SelectedPMH>
Medication List: <SelectedRx>
Allergies: <Reactions>

Recent investigations relevant to admission: (Please insert relevant investigations)

=============================================================================
Referring Doctor Details 

Doctor: <DrName>
Provider Nunber: <DrProviderNo>
Doctor Address: <DrAddress>
Phone: <DrPhone>
Fax: <DrFax>
Practice email: <DrEmail>

Version 6 (edited 30/08/2024)