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Standard referral information To be included in all referrals

Patient's Demographic Details

  • Full name (including aliases)
  • Date and country of birth
  • Residential and postal address including whether patient resides at an aged care facility
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Name of delegate and contact details (Department of Corrective Services)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander
  • Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature
  • Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • All conservative options that have been pursued unsuccessfully prior to referral
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes, BMI), noting these must be stable and controlled prior to referral
  • Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use
  • A comprehensive capture of information in relation to MSH Referral Criteria

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living functioning – low/medium/high
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

Clinic locations

The main centre is at Princess Alexandra Hospital with clinics also available at:

  • Bundaberg Hospital
  • Caloundra Hospital
  • Hervey Bay Hospital
  • Redcliffe Hospital
  • Logan Hospital
  • Gold Coast Hospital.

Urgent Referrals

Should a patient need to be seen urgently, contact the clinic and speak to either the Clinical Nurse Consultant/NUM or one of the medical staff.


Princess Alexandra Hospital:

  • Dr Geoffrey Playford (Director of Infection Management Services PAH)
  • Dr Hiranthi Walpola, SMO
  • Dr Mark Stickley, SMO
  • Dr Christine Logan, VMO
  • Dr Megan Evans, VMO
  • Dr John Armstrong, VMO
  • Dr Rachel Thomson, VMO
  • Dr Geoff Eather, VMO
  • Dr Chris Coulter, VMO

Patient must bring

  • Medicare card
  • Private health card
  • Any concession cards (e.g. Pension, Health Care, DVA, PBS Safety Net, ADF, etc)
  • Previous x-rays if not from a Queensland Health Hospital
  • List of any medication they are currently on.
Last updated 14 September 2018
Last reviewed 4 May 2017