GNEw9010SERV0010 GNEwDGNEw9010 GNEw GNEw9010ie GNEwGNEw90104 GNEw tListGNEw9010GNEwGNEw9010 GNEwGNEw9010heeTRPw up Back ColorTRPw0010IRPXIRPU Rt@dXXIRPW\\gpp-fp-07\HP LaserJet M3027 !C 4dXXA42FNIwF1FNIw0010 x MRPwSMRPw4010/= +ee+H++HH+HH++?XIPw XIPw301BORPw PRPw1010 TNFwTNFw0010Times New RomanArial Arial NarrowSymbolLTSwNormalLTSw0010PRPw1010  TTSw1010ABATw2010Times New Roman @@ @D@h@@@@@@@@d@@@  XR4000000AZ Metro North Health Service District - Royal Brisbane and Women's Hospital  OUTPATIENT REFERRAL FORM  Butterfield Street, Hertson, Qld 4029 Phone (07) 3636 6738 Fax: (07) 3636 7212  @@ @D@h@@@@@@@@d@@@============================================================================== . *Indicates mandatory information required Referring Doctor Details: @@* Doctor : ] JBO5   @9@ @@@* Provider No.: ] JBO5 !   @ @9@M@U@7@D@h@@@@@@@@d@ Doctor Address: ] JBO5 ] JBO5 ] JBO5 ] JBO5 @5@3@@@d@Phone: ] JBO5 @@3@D@h@@@@@@@@d@Fax: ] JBO5 @@@ @@5@M@U@7Patient s Usual G.P.  (if different from above):   Usual G.P. Provider No. ( if different from above) :   ======================================================================================== Refer to: ROYAL BRISBANE WOMENS HOSPITAL (XR4000000AZ) * Referral date: ]zzlJBO5ZNKOTNRTX& Show_CurrentDaten@n * Length of referral: 12 Months * Public Specialty referred to:   Doctors name :  Hospital outpatients Service Directory ]h*4KLHw00107RW4Ahttp://www.health.qld.gov.au/rbwh/gpconnect/service_directory.aspAhttp://www.health.qld.gov.au/rbwh/gpconnect/service_directory.asphttp://www.health.qld.gov.au/rbwh/gpconnect/service_directory.aspURL:http://www.health.qld.gov.au/rbwh/gpconnect/service_directory.asp   *If the patient is acutely unwell, please direct to Emergency Department* * Primary Reason for Referral / Provisional Diagnosis  (including history, duration, treatments & outcomes):  ] JBO5>! ] JBO5>  ======================================================================================== Patient Details:  Re: ] JBO5& @Z@#@@@@ * Surname: ] JBO5  * Given name: ] JBO5  @@@@#@Z * Date of Birth: ] JBO5  * Age: ] JBO5%    * Se x:  ] JBO5  @Q@@ *  Address: @@@@Q] JBO5 ] JBO5H ] JBO5 ] JBO5, ] JBO5+  @@ Postal Address  (if different from above):  @'@@@* Phone (Home): ] JBO5   @@@@' Phone (Work): ] JBO5!    Mobile: ] JBO5J  Alternate contact person: Alternate contact person phone number: Interpreter Required: Preferred Language   Medicare Number:  ] JBO5'    DVA Number:  ] JBO5# Occupation: ] JBO56 Health Insurance: ] JBO5: Workers Compensation claim: Relevant Medical and Surgical History:  @@>BBBB @@ Recent Investigations: @@ >BBBB @@ Relevant Social History: @ @@@>BBBB @@ Relevant Family History: @@>BBBB ] JBO5   @@ Medication List: @>BBBB]ddVJBO5DNKOTNRTX  Show_Scripts @  Allergies/ Adverse Events  (including medications / food / latex / environment eg grasses) : @@>BBBB]ffXJBO5FNKOTNRTX Show_Allergies @@ @@@@  !@@  Signed electronically: ] JBO5 >BBCCDate: ]zzlJBO5ZNKOTNRTX& Show_CurrentDaten@n ! @@7======================================================================================== @ @7 Metro North Health Service District - Royal Brisbane and Women's Hospital  Butterfield Street, Hertson, Qld 4029 Phone (07) 3636 6738 Fax: (07) 3636 7217 Sent via STS Secure electronic transfer to: ROYAL BRISBANE AND WOMENS HOSPITAL QHEALTH (XR4000000AZ) @@)RE: v5 28012010