GNEw90105 x SERV0010 GNEwGNEw9010GNEw oGNEw9010GNEwGNEw9010TGNEwGNEw9010GNEw nGNEw9010GNEw gleUnderlineGNEw9010TRPw tus barTRPw0010IRPXIRPU Rt@dXXIRPW\\gpp-fp-07\HP LaserJet M3027 !C 4dXXA4FNIwF1FNIw0010  MRPwMRPw4010/= +ee+H++HHHHHHH?XIPw XIPw301BORPw u BarPRPw1010  TNFwTNFw0010#Times New RomanArial Arial NarrowSymbol Cambria MathCalibriCambriaTimes New Roman CETimes New Roman CyrTimes New Roman GreekTimes New Roman TurTimes New Roman (Hebrew)Times New Roman (Arabic)Times New Roman BalticTimes New Roman (Vietnamese)Cambria Math CECambria Math CyrCambria Math GreekCambria Math TurCambria Math Baltic Calibri CE Calibri Cyr Calibri Greek Calibri TurCalibri BalticArial Narrow CEArial Narrow CyrArial Narrow GreekArial Narrow TurArial Narrow Baltic Cambria CE Cambria Cyr Cambria Greek Cambria TurCambria BalticLTSwNormalLTSw0010PRPw1010  TTSw1010ABATw2010Times New Roman@@@@d@@@@@@@@h@D@ @  . Metro North Health Service District Royal Brisbane and Women's Hospital OUTPATIENT REFERRAL FORM ============================================================================== Refer to: ROYAL BRISBANE WOMENS HOSPITAL (XR4000000AZ) Referral date:  ]zzlJBO5ZNKOTNRTX& Show_CurrentDaten@n Length of referral:    Specialist name: Specialty referred to:  (Please complete the  specialist name &  specialty referred to field by using the GPpartners handbook)    ***For URGENT referral, please phone the Registrar on- call via switch*** Primary Reason for Referral / Provisional Diagnosis  (including history, duration, treatments & outcomes):  ]hhZJBO5HNKOTNRTX ShowProblems_Long ============================================================================== Referring Doctor Details Doctor :  ] JBO5    Provider No.:  ] JBO5 !   Doctor Address:  ] JBO5 ] JBO5 ] JBO5 ] JBO5 >CCCC>@@CC @@ @@@@M@U@7 Phone : ] JBO5>f&@f&@BB  Fax : ] JBO5 @@M@U@7@@ @@ Patient s Usual G.P.  (if different from above): Usual G.P. Provider No. ( if different from above) :  ============================================================================== Patient Details  Re: ] JBO5& @Z@#@@@@ Surname:   ] JBO5   Given name:  ] JBO5   @#@Z@@@Preferred name:  ]jj\JBO5JNKOTNRTX Show_PreferredName  Date of Birth:  ] JBO5   Age:  ] JBO5%   Se x:  ] JBO5   @Q@@Address:  ] JBO5 ] JBO5H   @@@@Q ] JBO5 ] JBO5, ] JBO5+   @@ Postal Address  (if different from above):  @'@@@Phone (Home):  ] JBO5   @@@@' Phone (Work):  ] JBO5!    Phone (Mobile):  ] JBO5J   Alternate contact person: Relationship to Patient::  Alternate contact person phone number: Indigenous Status: Australian South Seas Islander Status: Interpreter Required: Preferred Language:  ] JBO5@    Medicare Number:  ] JBO5'   Patient Health Identifier: DVA Number: ] JBO5#  DVA Card Type:  Occupation:  ] JBO56  Health Insurance Provider:  ] JBO5:  Health Insurance Number:  ] JBO5d Workers Compensation claim: Workers Compensation claim number:  ] JBO5   ============================================================================== Patient Clinical Details Medication List: ]ddVJBO5DNKOTNRTX  Show_Scripts  Allergies/ Adverse Events  (including medications / food / latex / environment eg grasses) : ]ffXJBO5FNKOTNRTX Show_Allergies Recent Investigations: Smoking Status:  ] JBO5j   Alcohol Consumption:  ] JBO5  ============================================================================== Patient Clinical History Relevant Medical and Surgical History:  @@]hhZJBO5HNKOTNRTX ShowHistory_Short @@ @@ Relevant Social History: @@@@  @@  Relevant Family History: @@>BBBB @@==============================================================================  Verification ! Signed electronically: ] JBO5  >p=,Cp=,CCC Date: ]zzlJBO5ZNKOTNRTX& Show_CurrentDaten@n @7@! ============================================================================== @@7 Metro North Health Service District - Royal Brisbane and Women's Hospital  Butterfield Street, Herston, Qld 4029 Phone (07) 3636 4865 Fax: (07) 3636 7212 Sent via STS Secure electronic transfer to: ROYAL BRISBANE AND WOMENS HOSPITAL QHEALTH (XR4000000AZ) @)@RE: v2.2 110311