Submit a Referral
Experts in Transitions
Hospital Referral
Referral will be responded to within 2 hours.
"
*
" indicates required fields
Patient Details
Patient's First Name
*
Patient's Last Name
*
Gender
Male
Female
Non-Binary
Prefer Not To Say
Patient’s Date of Birth
*
DD slash MM slash YYYY
Preferred Language
*
English
Afrikaans
Albanian
Amharic
Arabic
Armenian
Bangla (Bengali)
Bosnian
Bulgarian
Burmese
Cantonese
Croatian
Czech
Danish
Dari
Dinka
Dutch
Estonian
Farsi (Persian)
Fijian
Filipino
Finnish
French
Gaelic
German
Greek
Hindi
Hmong
Hungarian
Indonesian
Italian
Japanese
Khmer
Korean
Lao
Latvian
Lithuanian
Macedonian
Malay
Maltese
Mandarin
Maori
Norwegian
PNG Pidgin
Polish
Portuguese
Romanian
Romany
Russian
Samoan
Serbian
Sinhalese
Slovak
Slovenian
Spanish
Swahili
Swedish
Tamil
Tetun
Thai
Tongan
Turkish
Ukrainian
Urdu
Vietnamese
Welsh
Other / not listed
Other Language
*
Optional: Communication support required?
Auslan
Deaf interpreting
Other support needs
Other support needs
*
Interpreter Required?
*
Yes
No
Placement Category
Select Relevant Categories
*
Low Care
Dementia
Bariatric
Limited Mobility
Diabetes
Disability
Smoker
RACF/ACAP
Cultural
Equipment and Supplies Needed
Select Relevant Categories
*
Hospital Bed
Pressure-Relieving Mattress
Oxygen
Shower Chair
Commode
Hoist
Mobility Aids Details
Other Details
Equipment To Be Supplied By
*
Hospital
My Aged Care
DVA
Private
Tea-cup Cottage
Current Medication
Medication
Dose
Frequency
Route
Administration by RN/EN?
Yes
No
Add Medication
+ Add Medication
Medication
Dose
Frequency
Route
Administration by RN/EN?
Yes
No
Add Medication
+ Add Medication
Medication
Dose
Frequency
Route
Administration by RN/EN?
Yes
No
Add Medication
+ Add Medication
Medication
Dose
Frequency
Route
Administration by RN/EN?
Yes
No
Add Medication
+ Add Medication
Medication
Dose
Frequency
Route
Administration by RN/EN?
Yes
No
Add Medication
+ Add Medication
Medication
Dose
Frequency
Route
Administration by RN/EN?
Yes
No
Add Medication
+ Add Medication
Medication
Dose
Frequency
Route
Administration by RN/EN?
Yes
No
Add Medication
+ Add Medication
Medication
Dose
Frequency
Route
Administration by RN/EN?
Yes
No
Add Medication
+ Add Medication
Medication
Dose
Frequency
Route
Administration by RN/EN?
Yes
No
Add Medication
+ Add Medication
Medication
Dose
Frequency
Route
Administration by RN/EN?
Yes
No
Additional Medication Notes
Hospital Information
Select Health Service
*
Health Service
Metro North Hospital and Health Service
Metro South Hospital and Health Service
Gold Coast Hospital and Health Service
Select Hospital
*
Select Hospital
Caboolture Hospital (CABH)
Kilcoy Hospital (KH)
Redcliffe Hospital (REDH)
Royal Brisbane and Women’s Hospital (RBWH)
Surgical, Treatment and Rehabilitation Service (STARS)
The Prince Charles Hospital (TPCH)
Select Hospital
*
Select Hospital
Beaudesert Hospital (BEAH)
Logan Hospital (LOGH)
Princess Alexandra Hospital (PAH)
Queen Elizabeth II Jubilee Hospital (QEII)
Redland Hospital (RH)
Select Hospital
*
Select Hospital
Gold Coast University Hospital (GCUH)
Robina Hospital (ROB)
Varsity Lakes Day Hospital (VLDH)
Ward / Unit
*
Reason for Admission
*
Date of Admission
*
DD slash MM slash YYYY
Estimated Discharge Date
*
DD slash MM slash YYYY
Referring Contact
*
Referring Officer
*
Referring Contact Position
*
Phone
*
Email
*
Discharge Summary Provided
*
Yes
No
Other Details
Insert Any Other Comments Here
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