Children’s Health Queensland Hospital and Health Service (LCCH USE ONLY – affix patient identification label here) Specialist Referral Fax completed form to Lady Cilento Children’s Hospital Referrals on 1300 407 281 • To ensure a timely appointment complete all sections. Incomplete forms will be returned for completion. • Information and resources are available at www.childrens.health.qld.gov.au/referapatient • Please direct an acutely unwell child to the Emergency Department Refer to a Specialty by selecting a  Head of Clinic from the list below. Referrals are shared with other Specialists in the clinic to ensure patients are seen as quickly as possible. DO NOT WRITE IN THIS BINDING MARGIN Infectious Diseases Dr Julia Clark Gait Laboratory Dr John Walsh Gastroenterology and Hepatology Dr Andrew Hallahan Gender Clinic Dr Stephen Stathis General Paediatrics Dr David Levitt Genetics Dr Julie McGaughran Gynaecology (Paediatric and Adolescent) Dr Rebecca Kimble Haematology Dr Simon Brown Immunology and Allergy Dr Jane Peake Liver Transplant Dr Jonathan Fawcett Metabolic Dr Jim McGill Nephrology Dr Peter Trnka Neurology Dr Geoff Wallace Neurosurgery Dr Michael Redmond Ophthalmology Prof Glen Gole Orthopaedic Surgery/ Fracture Dr Geoff Donald Oncology Prof Ross Pinkerton Oral and Maxillofacial Surgery Dr Ben Erzetic Pain Clinic Dr Kathleen Cooke Palliative Care Dr Anthony Herbert Plastic and Reconstructive Surgery Dr Stuart Bade Rehabilitation/ Cerebral Palsy Health Dr Priya Edwards Respiratory/ Sleep Medicine Dr Carolyn Dakin Rheumatology Dr Navid Adib Dr Ben Whitehead Paediatric Surgery and Urology Prof Roy Kimble Vascular Malformations Prof Roy Kimble Dr Stuart Bade OR referral to (named specialist): REFERRAL DATE: Length of Referral: 3 months (standard referral from a Specialist) Indefinite (chronic conditions only) 12 months (standard referral from a GP) Telehealth Referral PATIENT DETAILS [ Referral of new patients are accepted before their 17th birthday ] v15.00 - 02/2015 Name: Medicare eligible: Sex: No F Date of birth: M Age: Yes  Medicare no: Card reference no: Expiry date: Residential address: 00007:500020 Í È7:ÇR 4 Î Suburb: State: Postcode: Parent/Guardian/Agency name: Ph (home): Relationship to patient: Parent/Guardian/Agency contact details: Aboriginal or Torres Strait Islander status: Aboriginal but not Torres Strait Islander origin Both Aboriginal & Torres Strait Islander origin Torres Strait Islander but not Aboriginal origin Neither Aboriginal, nor Torres Strait Islander origin Interpreter required? No Yes  preferred language: Private health insurance: No Yes Compensable status: Third Party Personal injury Page 1 of 2 Workcover Qld Not stated DVA Continued next page SPECIALIST REFERRAL Burns Prof Roy Kimble Cardiothoracic Surgery Dr Nelson Alphonso Cardiology Dr Robert Justo Child Protection & Forensic Medicine Dr Jan Connors Child Development Dr Honey Heussler Children’s Oral Health Service Dr Steve Atkin Dermatology Dr Terry Casey Emergency Department Dr Jason Acworth Endocrinology/Diabetes Dr Jerry Wales ENT/Otolaryngology Dr Rob Black Family name: Given names: URN: REASON FOR REFERRAL Please explain if you consider the referral urgent: Past history or additional comments: DO NOT WRITE IN THIS BINDING MARGIN Current medications: Allergies: Immunisation status: Social history and/or psychosocial risk factor/s: Relevant family history: What additional documents have been faxed or sent? RELEVANT INVESTIGATIONS  PLEASE ATTACH COPIES REFERRING DOCTOR DETAILS Name: Provider no: Practice address: Suburb: State: Phone: Fax: Postcode: Patient’s usual GP (if different from referrer): Is anyone else involved in the care of the patient? Doctor’s signature: Page 2 of 2 Print Form