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
(BP V5.1, June 2024)

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: <TodaysDate>

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PATIENT DETAILS
RE: <PtFirstName> <PtSurname>		DOB: <PtDoB>
Preferred Name: <PtPrefName>
IHI No.: <PtIHI>
Address:<PtStreet>, <PtCity>, <PtState> <PtPostcode> 
Home Phone:<PtPhoneH>
Mobile Phone:<PtPhoneMob>
Medicare No.: <PtMCNo> <PtMCLine>		Expiry: <PtMCExpiry>
DVA No.: <PtDVANo>				Card Type: <PtDVACard>

Preferred Language:  <Patient's preferred language>
Interpreter required: <Is an interpreter required>
Ethnicity: <PtEthnicity>
ATSI Status: <Aboriginal and Torres Strait Islander Status>
Country of Birth: <Country of Birth>

Compensable status: <Patient's compensable status>
Other Compensable Status: <If other compensable status not listed above, please specify:>

Parent/caregiver name: <Parent/caregiver name (if applicable)>
Parent/caregiver relationship to patient: <Parent/Caregiver relationship to patient (If Applicable)>
Parent/caregiver contact details:  <Parent/caregiver contact details (if applicable)> 

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REFERRAL DETAILS
Referral type: <Referral type>
Priority: <Referral priority>
Referral length: <Referral Length>

Specialty referred to: <Specialty referred to> 
If other specialty, please specify: <Other specialty referred to if not listed above>
Clinical condition: <Clinical condition (e.g. PR Bleeding)>
Primary reason for referral:  <Primary reason for referral/presenting condition (E.g. abdominal pain - Please include ALL standard, essential referral as per: https://metrosouth.health.qld.gov.au/referrals)>
Relevant secondary reasons for referral: <Relevant secondary reasons for referral (eg coeliac, polyp surveillance)>

Choice to be treated as public or private patient: <Choice to be treated as public or private patient>
Choice of consultant referred to: <Choice of consultant referred to as private patient (Please specify 'name' as per: https://metrosouth.health.qld.gov.au/referrals/specialists)>
Hospital: <Hospital>

Clinical modifiers: <Clinical modifier/s that may impact patient priority (Select all that apply)>
Additional information for clinical modifiers: <Please add any additional information that may modify patient priority>

Telehealth consultation: <Does the patient want a telehealth consultation?>

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MEDICAL HISTORY
ACTIVE MEDICAL HISTORY: 
<PMHActive> 

INACTIVE MEDICAL HISTORY: 
<PMHInactive>

CURRENT MEDICATION:
<CurrentRx>

ALERTS: 
<Reactions>

SOCIAL HISTORY: 
<SocialHx>

FAMILY HISTORY: 
<FamilyHx>

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REFERRING DOCTOR DETAILS
Name: <DrName>
Qualifications: <DrQualifications>
Provider No: <DrProviderNo>
Practice Name: <Practice>
Address: <DrAddress>
Phone: <DrPhone>
Fax: <DrFax>

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

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VERIFICATION
Electronically Signed: <DrName>
<DayAndDate>

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OBSERVATIONS
<Observations>

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INVESTIGATIONS
<Ix>