General Surgical Outpatient Department Please ensure that all relevant investigations accompany this referral.
Secure transmission service via Medical Objects, Healthlink or Argus Ipswich Hospital Outpatient Clinic
Chelmsford Ave, Ipswich QLD 4305
PH: 07 3810 1111
Fax: 07 3810 1438 Date of Referral:
Is this an urgent or non urgent referral? Reason for Referral ( Free Text ):
Include as much relevant information as possible about your patient's condition to optimise their chances of being triaged correctly eg diagnosis, duration, severity and impact.Please ensure all baseline investigations as per the pre referral guidelines accompany this referral. Test results should be dated within 3 months of referral date. Dear: FROM:
*[Medicare ineligible patients will incur an appointment fee]
Alternative Contact Name: Alt. Contact’s Phone:
[Alternative contact may be used to contact the patient if they cannot be reached via the contact details given]
Interpreter Required: please specify Language:
Is there results/investigations that will be faxed to the hospital to accompany this referral that could notbe sent electronically?If yes,ensure all pages are clearly marked with the patients full name, date of birth and referring doctor and fax to: 07 3810 1438
Please use this guide to complete the appropriate tests and investigations so patients can be accurately triaged within the SURGICAL Outpatients Department.
All referrals should include:
complete patient / family history relevant to the patient’s condition or complaint
Please indicate if lifestyle modifications have been implemented as part of the overall management of the patient symptoms i.e. Smoking cessation, dietary modification, weight loss, increasedexercise.
All investigation results are to accompany the patient referral when sent to SURGICAL Outpatients Department. Test results should be dated within three (3) months of referral date.