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 <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

Dear Doctor

<Specialty and Doctor>

Patient details

RE: <PtFullName>
DOB: <PtDoB>
AGE: <PtAge>

Gender: <PtSex>
Address: <PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>
Medicare Number*: <PtMCNo> (*Medicare ineligible patients will incur a consultation fee)
Medicare Expiry: <PtMCExpiry>
DVA Number: <PtDVANo>
DVA Expiry: <DVA expiry>	Next of Kin/Alternative Contact: <NOKName>
Next of Kin/Alternative Contact Ph: <NOKContact>
Does patient identify as Aboriginal and/or Torres Strait Islander: <Does pt identify as Aboriginal/Torres Strait Islander>
Interpreter required: <Interpreter required>
If yes, specify language: <If yes, specify language>
Patient suitable for telehealth if available: <Pt suitable for telehealth if available>	

Reason for referral

Reason for referral: <Specify main reason for referral>

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

<Ix>

Medical history

Past Medical History: <PMHAll>

Allergies: <Reactions>

Current prescribed medications: <CurrentRx>

Smoking: <SmkStatus> <SmkHx>

Alcohol: <AlcHx>