Author: Jenaya Price

Central Referral Hub
Refer Your Patient 
Metro South Health Referral Form
PO Box 4195, Eight Mile Plains, QLD 4113
Phone: 1300 364 155     Fax: 1300 364 248
(Zedmed V5.1, September 2022)

Referrals are to be sent via secure electronic transfer to -
Medical Objects:  MSH Central Referral Hub (MQ4113000HC)
HealthLink: qldmshrh

Preferred method for referrals is GP Smart Referrals

<*NOTE: Kiteworks is for urgent referrals with attachments that can't be sent via secure messaging or fax>

Referral date: Miscellaneous.Date

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PATIENT DETAILS
RE: Patient Demographics.Full NameDOB: Patient Demographics.DOB
Preferred Name: Patient Demographics.Popular Name
IHI No.: Patient Demographics.IHI Number
Address:Patient Demographics.Full Address
Home Phone:Patient Demographics.Phone (Home)
Mobile Phone:Patient Demographics.Phone (Mobile)
Medicare No.: Patient Demographics.Medicare NumberExpiry: Patient Demographics.Medicare Expiry Date
DVA No.: Patient Demographics.DVA Number Patient Demographics.DVA Expiry Date			Card Type: DVA Card Type 

Preferred Language:  Preffered Language 
Interpreter required: Interpreter Required
Ethnicity: Ethnicity?
ATSI Status:Patient Demographics.ATSI Status
Country of Birth: Country of Birth 

Compensable status:Patient's Compensabl
Other Compensable Status: Other Compensable St

Parent/caregiver name: Parent/caregiver Nam
Parent/caregiver relationship to patient: Parent/caregiver rel
Parent/caregiver contact details:  Parent/caregiver con
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REFERRAL DETAILS
Referral type: Referral Type 
Priority:Referral Priority 
Referral length: Referral Length 

Specialty referred to: Specialty referred 
If other specialty, please specify:Other specialty
Clinical condition: Clinical Condition 
Primary reason for referral:  Primary reason for r
Relevant secondary reasons for referral: Relevant secondary r

Choice to be treated as public or private patient: Public or private 
Choice of consultant referred to: Choice of consultant
Hospital: Hospital 

Clinical modifiers: Clinical modifiers 
Additional information for clinical modifiers: Additional info 

Telehealth consultation: Telehealth consultat

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MEDICAL HISTORY
ACTIVE MEDICAL HISTORY: 
Clinical Details.Past History

INACTIVE MEDICAL HISTORY: 
Clinical Details.Problem List (Resolved) With Comments, Onset Year

CURRENT MEDICATION:
Clinical Details.Medication List

ALERTS: 
Clinical Details.Warnings

SOCIAL HISTORY: 
Clinical Details.Social History

FAMILY HISTORY: 
Clinical Details.Family History

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REFERRING DOCTOR DETAILS
Name: Treating Doctor.Name
Qualifications: Treating Doctor.Qualifications
Provider No: Treating Doctor.Provider Number
Practice Name: Practice.Name
Address: Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax

Any other practitioner involved in care of the patient: <Other practitioner?
Patient's usual GP (if different from referrer): Usual GP

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VERIFICATION
Electronically Signed: Treating Doctor.Name
Miscellaneous.Date

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OBSERVATIONS
<Observations>

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INVESTIGATIONS
<Ix>

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RE: Patient Demographics.Full Name      DOB: Patient Demographics.DOB      MSHHS RYP Zedmed V5.1  Sept  2022    Page