Children`s Health Queensland Specialist Referral Form

Children’s Health Queensland
Hospital and Health Service
(LCCH USE ONLY – affix patient identification label here)
Specialist Referral
Fax completed form to Lady Cilento Children’s Hospital Referrals on 1300 407 281
• To ensure a timely appointment complete all sections. Incomplete forms will be returned for completion.
• Information and resources are available at www.childrens.health.qld.gov.au/referapatient
• Please direct an acutely unwell child to the Emergency Department
Refer to a Specialty by selecting a  Head of Clinic from the list below. Referrals are shared with other Specialists in the
clinic to ensure patients are seen as quickly as possible.
DO NOT WRITE IN THIS BINDING MARGIN
Infectious Diseases
Dr Julia Clark
Gait Laboratory
Dr John Walsh
Gastroenterology and
Hepatology
Dr Andrew Hallahan
Gender Clinic
Dr Stephen Stathis
General Paediatrics
Dr David Levitt
Genetics
Dr Julie McGaughran
Gynaecology (Paediatric
and Adolescent)
Dr Rebecca Kimble
Haematology
Dr Simon Brown
Immunology and Allergy
Dr Jane Peake
Liver Transplant
Dr Jonathan Fawcett
Metabolic
Dr Jim McGill
Nephrology
Dr Peter Trnka
Neurology
Dr Geoff Wallace
Neurosurgery
Dr Michael Redmond
Ophthalmology
Prof Glen Gole
Orthopaedic Surgery/
Fracture
Dr Geoff Donald
Oncology
Prof Ross Pinkerton
Oral and Maxillofacial
Surgery
Dr Ben Erzetic
Pain Clinic
Dr Kathleen Cooke
Palliative Care
Dr Anthony Herbert
Plastic and
Reconstructive Surgery
Dr Stuart Bade
Rehabilitation/
Cerebral Palsy Health
Dr Priya Edwards
Respiratory/
Sleep Medicine
Dr Carolyn Dakin
Rheumatology
Dr Navid Adib
Dr Ben Whitehead
Paediatric Surgery
and Urology
Prof Roy Kimble
Vascular Malformations
Prof Roy Kimble
Dr Stuart Bade
OR referral to (named specialist):
REFERRAL DATE:
Length of Referral:
3 months (standard referral from a Specialist)
Indefinite (chronic conditions only)
12 months (standard referral from a GP)
Telehealth Referral
PATIENT DETAILS [ Referral of new patients are accepted before their 17th birthday ]
v15.00 - 02/2015
Name:
Medicare eligible:
Sex:
No
F Date of birth:
M
Age:
Yes  Medicare no:
Card reference no:
Expiry date:
Residential address:
00007:500020
Í È7:ÇR 4 Î
Suburb:
State:
Postcode:
Parent/Guardian/Agency name:
Ph (home):
Relationship to patient:
Parent/Guardian/Agency contact details:
Aboriginal or Torres Strait Islander status:
Aboriginal but not Torres Strait Islander origin
Both Aboriginal & Torres Strait Islander origin
Torres Strait Islander but not Aboriginal origin
Neither Aboriginal, nor Torres Strait Islander origin
Interpreter required?
No
Yes  preferred language:
Private health insurance:
No
Yes
Compensable status:
Third Party
Personal injury
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Workcover Qld
Not stated
DVA
Continued next page
SPECIALIST REFERRAL
Burns
Prof Roy Kimble
Cardiothoracic Surgery
Dr Nelson Alphonso
Cardiology
Dr Robert Justo
Child Protection &
Forensic Medicine
Dr Jan Connors
Child Development
Dr Honey Heussler
Children’s Oral Health
Service
Dr Steve Atkin
Dermatology
Dr Terry Casey
Emergency Department
Dr Jason Acworth
Endocrinology/Diabetes
Dr Jerry Wales
ENT/Otolaryngology
Dr Rob Black
Family name:
Given names:
URN:
REASON FOR REFERRAL
Please explain if you consider the referral urgent:
Past history or additional comments:
DO NOT WRITE IN THIS BINDING MARGIN
Current medications:
Allergies:
Immunisation status:
Social history and/or psychosocial risk factor/s:
Relevant family history:
What additional documents have been faxed or sent?
RELEVANT INVESTIGATIONS  PLEASE ATTACH COPIES
REFERRING DOCTOR DETAILS
Name:
Provider no:
Practice address:
Suburb:
State:
Phone:
Fax:
Postcode:
Patient’s usual GP (if different from referrer):
Is anyone else involved in the care of the patient?
Doctor’s signature:
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