WCH Outpatient Referra Form header

For best results, please use the Google Chrome browser with this form

Client Details

Surname:             First name:  
Middle name/s: 

Date of birth:         Gender:    WCH UR No. (enter if known)

Address:           

State:                

Phone:    Home:   Work:   Mobile:

Is the client of Aboriginal or Torres Strait Islander origin?    

Is this client under the Guardianship of the Minister?    

Interpreter required:  

Client Medicare number:  

If under 18 years, please provide parent/carer name:

                Surname:     First name:

Referral Information

Length/duration of Referral:

Clinic

Dear 

Presenting Problem/s:

Please provide information on presenting issue, and forward any pathology and x-ray reports to help determine the priority assigned to the client.

Current / Other Medical Problems

Please provide information to help determine the priority assigned to the client - note current medications, relevant allergies and immunisations.

Referring Clinic Details

Referring Doctor name:    Surgery name:

Provider number:           

Address:

State:     

Phone number:     Fax number:

Signature:    Date:  

Please PRINT, SIGN and DATE this form, then FAX it to the
Women's and Children's Hospital Administration Hub on 8161 6246