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- Ipswich Hospital Outpatient Clinic Chelmsford Ave, Ipswich QLD 4305 PH: 07 3810 1111 Fax: 07 3810 1438
- Dear: FROM
- Date
- Smoking Status
- All referrals should include: complete patient / family history relevant to the patient’s condition or complaint medication
- Does the patient have a current GP management plan/team care arrangement
- Is this a new or pre-existing condition
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REQUEST FOR CONSULTATION Ipswich Hospital 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: HPI-I: Practice Name: Practice Address: Practice HPI-O: Phone: Fax: Email: Provider Number: Date: RE: DOB: Gender: Medicare Number*: *[Medicare ineligible patients will incur an appointment fee] Patient IHI: Street Address: Home Ph: Mobile Ph: Alternative Contact Name: [Alternative contact may be used to contact the patient if they cannot be reached via the contact details given] Smoking Status: Alcohol Status: Social History: Interpreter Required: Is there results/investigations that will be faxed to the hospital to accompany this referral that could not be sent electronically? 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:
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, increased exercise. 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.
Is this a new or pre-existing condition: Is the patient experiencing pain or a degree of loss of function due to this condition? Relevant Medical History: Allergies: Current Medications: Results: Yours Sincerely Directory: media media -> Acronyms 3 Mission Context and Background 5 media -> Comemmoration of the bill for the abolition of the slave trade media -> Reflections on the 20 media -> Chapter eleven: the presidency media -> Ma history Module Information ‘American Foreign Relations’ Synopsis media -> Assumptions of Asian American Similarity: The Case of Filipino and Chinese American Students media -> Latin America and the Caribbean in the Age of Revolution media -> Cecelia Quinn Dissertation Research media -> United States History Assessments Ninth Grade Download 38.47 Kb. Share with your friends:
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