GNEw9010% x SERV0010 GNEwGNEw9010GNEw oGNEw9010GNEwGNEw9010TGNEwGNEw9010GNEw nGNEw9010GNEw gleUnderlineGNEw9010TRPwLanguagesTRPw0010IRPXIRPU Rt@dXXIRPW\\gpp-fp-07\HP LaserJet M3027 !C 4dXXA4FNIwR1FNIw0010  :MRPwSMRPw4010w.A +ee+H++HHHHHH?XIPwFormats XIPw301BORPw u BarPRPw1010  TNFwColorsTNFw0010#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 BalticLTSwNormallaneousLTSw0010PRPw1010  TTSw1010ABATw2010Times New Roman@@@@d@@@@@@@@h@D@ @ . Children's Health Services  Royal Children s Hospital OUTPATIENT REFERRAL FORM ============================================================================== Refer to: ROYAL CHILDRENS HOSPITAL QHEALTH (RQ402900084)  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)  Primary Reason for Referral / Provisional Diagnosis  (including history, duration, treatments & outcomes):  ]jj\JBO5JNKOTNRTX ShowProblems_Short  Previous admission details (if known): Previous admission date:   If the patient is acutely unwell, please direct to Emergency Department If the patient is over 15 years of age at time of referral, it may be returned and/or forwarded to Adult Services  ============================================================================== 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: ============================================================================== Patient Clinical Details Medication List: ]ddVJBO5DNKOTNRTX  Show_Scripts  Allergies/ Adverse Events  (including medications / food / latex / environment eg grasses) : ]ffXJBO5FNKOTNRTX Show_Allergies Recent Investigations: ============================================================================== Patient Clinical History Relevant Medical and Surgical History:  @@]hhZJBO5HNKOTNRTX ShowHistory_Short @@ Immunisation History: @@  ]jj\JBO5JNKOTNRTX Show_Immunisationsb @@  Relevant Social History: @@ @@ Relevant Family History: @@ @@@@ ============================================================================== Verification @ @ ! Signed electronically: ] JBO5  >G(CG(CCC Date: ]zzlJBO5ZNKOTNRTX& Show_CurrentDaten@n @7@! ==============================================================================  Royal Children s Hospital, Children s Health Services @@7Level 1 Surgical Building, Royal Children s Hospital, Herston Road, Brisbane, Qld 4029 !Phone (07) 3636 7818 Fax: (07) 3636 7811 @)@!  STS Secure electronic transfer to: ROYAL CHILDRENS HOSPITAL QHEALTH (RQ402900084) RE: v2.2 110311