e e GNEw9010 L SERV0010 GNEwFGNEw9010GNEwUnderlinesGNEw9010: Hospital Administration Use Only: Affix patient label hereGNEwPGNEw9010GNEwBorder Lines StylesGNEw9010GNEwSGNEw9010GNEwBGNEw9010TRPwTabulationsTRPw0010IRPXIRPU Rt dXXIRPW\\GPQSVR04VM04\Utilities RICOH C 4dXXA4FNIwE1FNIw0010 b5MRPwMRPw4010w.A ++HHHH?XIPwNumberFormats XIPw301BORPwCPRPw1010  TNFwN`TNFw0010Times New RomanArial Arial NarrowTimes 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)Arial CE Arial Cyr Arial Greek Arial TurArial (Hebrew)Arial (Arabic) Arial BalticArial (Vietnamese)Arial Narrow CEArial Narrow CyrArial Narrow GreekArial Narrow TurArial Narrow BalticLTSwNormalLTSw0010PRPw1010  TTSw1010ABATw2010Times New Roman @@@@d@@@@@@@@h@D@ @ BUNDABERG HOSPITAL OUTPATIENT REFERRAL FORM v10/12 =========================================================================== REFERRAL:  Date of referral: ] JBO5/ @#$y@Referral validity duration: Please delete items which are not applicable "l12 months 3 months Indefinite Assessment & referral back "  Reason for referral:  @@7@@$# =========================================================================== @@7REFERRAL TO:  Organisation: Bundaberg Hospital (XB4670000X6) Clinic referred to: Doctors Name: ]&64KLHw00107RW4List of SpecialistsKhttp://www.gpqld.com.au/icms_docs/98417_Bunderberg_eRefferal_GP_Links.pdf List of SpecialistsURL:http://www.gpqld.com.au/icms_docs/98417_Bunderberg_eRefferal_GP_Links.pdf    Clinic referred to (where no specific doctor has been nominated):   Address: Bourbong Street, Bundaberg, Qld 4670 Phone: 07 4150 2120 Fax: 07 4150 2129 @7@=========================================================================== @@7REFERRAL FROM:  Referring clinician: ] JBO5  Organisation: ] JBO5 Address: ] JBO5, ] JBO5, ] JBO5, ] JBO5 Phone: ] JBO5 Email: ] JBO5 Fax: ] JBO5 Provider number: ] JBO5 ! @7@=========================================================================== @@7PATIENT DETAILS: Re: ] JBO5& Surname: ] JBO5 Given name: ] JBO5 DOB: ] JBO5 Sex: ] JBO5 Preferred language: Interpreter required:   Indigenous status: Please delete items which are not applicable  "l@@$ Neither Aboriginal nor Torres Strait Islander Aboriginal but not Torres Strait Islander Torres Strait Islander but not Aboriginal Both Aboriginal and Torres Strait Islander Not Stated/Unknown " Australian South Sea Islander status:  @$@  Please delete items which are not applicable "lYes No  "Address: ] JBO5U ] JBO5, ] JBO5, ] JBO5+, ] JBO5, @@@@'Phone (home): ] JBO5 @@@@'Phone (work): ] JBO5! Phone (mobile): ] JBO5J Medicare card number: ] JBO5' DVA card number: ] JBO5# #h$@@@@$ Compensable status:  Please delete items which are not applicable "lEligible Public Eligible Third Party (Motor Vehicle Third Party Insurance / Third Party Insurance) WCBQ Eligible Compensable (Qld Workers' Compensation Act / Other Workers' Compensation Act) Other Eligible Compensable (Under the Criminal Code) Eligible Other (Private patient) #$y@@$@@" Hospital insurance status: #$@@ Please delete items which are not applicable "lYes #$y@@No "Private health insurance fund: ] JBO5: @@7@@$# =========================================================================== @@7PATIENT CLINICAL INFORMATION: Current medications: (please list and provide description, dosage, route, dose quantity, frequency and any additional instructions) @2@ Current Medications: ]ddVJBO5DNKOTNRTX  Show_Scripts @2@  Warnings / alerts:  Allergies/ adverse reactions: (Please list and including reaction description)  Allergies: ]ffXJBO5FNKOTNRTX Show_Allergies  Recent investigations / test results: (including type, name, date, result status, results)  Smoking status: ] JBO5j Alcohol consumption: ] JBO5  Existence of Advanced Healthcare Directive: @7@=========================================================================== @@7PATIENT CLINICAL HISTORY: Relevant medical and surgical history: (including treatments, medications, outcomes, date/time range) Relevant social:(including employment, education, home, finances and activities of daily living)   Relevant family history:  @@2 ] JBO5 @2@ Special needs and/or psychosocial issues: @7@=========================================================================== @@7USUAL GP (if different): @9@@@Name and Organisation: ] JBO58 @7@U@M@ @9@Contact details: @@@ @7@@M@U@7=========================================================================== @@7ALTERNATE CONTACT(S): @Z@#@@@@Alternate Contact name (First name, Family name): ] JBO5F Relationship to patient: @@'@#@ZAlternate Contact contact details: ] JBO5G @@7@@'=========================================================================== @@7VERIFICATION: @2@ Doctors Full Name: ] JBO5  @@2Date: ]zzlJBO5ZNKOTNRTX& Show_CurrentDaten@n @7@=========================================================================== @@7Sent via STS Secure electronic transfer to: BUNDABERG HOSPITAL @)@Form version: 07/11 >CCCC