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: <<Miscellaneous:Date>>
Accepting VW Clinician:<<Accepting Virtual Ward clinician>>
Secure electronic transfer to: Metro North Central Patient Intake (MQ4006000A4)
=============================================================================
Patient details

Patient name:  <<Patient Demographics:Full Name>>
Preferred name:  <<Patient preferred name>>
DOB: <<Patient Demographics:DOB>>
Age: <<Patient Demographics:Age>>
Sex: <<Patient Demographics:Sex at Birth>>

Medicare Number: <<Patient Demographics:Medicare Number>>
DVA Number: <<Patient Demographics:DVA Number>>
Health Insurance Provider: <<Patient Demographics:Health Insurance>>

Residential Address: <<Patient Demographics:Full Address>>

Phone (Home): <<Patient Demographics:Phone (Home)>>
Phone (Mobile):  <<Patient Demographics:Phone (Mobile)>>

Alternate contact person/carer:  <<Alternate contact person>>
Relationship to patient:  <<Relationship to Patient>>
Alternate contact person phone number:  <<Alternate contact person phone number>>

Does your patient identify as Aboriginal or Torres Strait Islander? <<Patient Demographics:ATSI>>

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

If you answered “Yes” to any of the above questions, please provide further details <<if yes to any of the above, provide further details>>

==============================================================================
Primary Reason for Referral: 

Relevant history and background: <<Clinical Details:History List>>

Proposed management plan for the Virtual ward: <<Proposed management plan for the Virtual Ward>>

Past Medical and Surgical History: <<Clinical Details:History List>>
Medication List: <<Clinical Details:Medication List>>
Allergies: <<Clinical Details:Allergies/Adverse Reactions>>

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

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

Doctor: <<Doctor:Name>>
Provider Number: <<Doctor:Provider Number>>
Doctor Address: <<Practice/Location:Address>>
Phone: <<Practice/Location:Phone>>
Fax: <<Practice/Location:Fax>>
Practice email: <<Practice/Location:E-mail>>

Version 6 (edited 30/08/2024)