REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE

SEND TO
Secure transmission service via Medical Objects or  
Healthlink to
QHEALTH, GOLD COAST HEALTH Outpatients
Outpatient Bookings and Referrals

OR

Fax: 07 5687 4497	From Treating Doctor.Name
Practice.Name
Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Email: Treating Doctor.E-mail
Provider Number: Treating Doctor.Provider Number

Miscellaneous.Date

Dear Doctor

Specialty / Doctor

Patient details

RE: Patient Demographics.Full Name
DOB: Patient Demographics.DOB
AGE: Patient Demographics.Age

Gender: Patient Demographics.Gender
Address: Patient Demographics.Address
Home Ph: Patient Demographics.Phone (Home)
Mobile Ph: Patient Demographics.Phone (Mobile)
Medicare Number*: Patient Demographics.Medicare Number  (*Medicare ineligible patients will incur a consultation fee)
Medicare Expiry: Patient Demographics.Medicare Expiry Date
DVA Number: Patient Demographics.DVA Number
DVA Expiry: Patient Demographics.DVA Expiry Date	Next of Kin/Alternative Contact: Patient Demographics.NOK Name
Next of Kin/Alternative Contact Ph: Patient Demographics.NOK Mobile Phone
Does the patient identify as Aboriginal and/or Torres Strait Islander: Does the pt identify
Interpreter required: Interpreter required
If yes, specify language: If yes, specify lang
Patient suitable for telehealth if available: Pt telehealth	

Reason for referral

Reason for referral: Specify main reason 

Please indicate how long you would like your referral to remain valid: Duration of referral

Please address all Essential Referral Criteria as listed on Gold Coast Refer Your Patient website

https://www.goldcoast.health.qld.gov.au/referrals

Investigations

Clinical Details.Result List (Selected)

 Medical history

Past medical history: Clinical Details.Past History
Clinical Details.Problem List (Current) With Comments
Clinical Details.Problem List (Resolved) With Comments

Allergies: Clinical Details.Allergies

Current prescribed medications: Clinical Details.Medications - Current Regular

Smoking: Clinical Details.Smoking

Alcohol: Clinical Details.Alcohol