Referral to Women’s and Children’s Hospital Out Patient Department

Client Details
Surname: <PtSurname>
			
First Name: <PtFirstName>
	Middle Name/s: <PtMidName>		
Date of Birth: <PtDoB>
	Gender: <PtSex>	WCH UR (if known): <WCH UR (if known):>	
Address: <PtAddress>
	
Suburb: <PtCity>
	Postcode: <PtPostcode>	
Is the client of Aboriginal or Torres Strait Islander origin? <Is the client of Aboriginal or Torres Strait Islander origin>
	
Is this client under the Guardianship of the Minister? <Is this client under the Guardianship of the Minister?>
	
Is an interpreter required? <Is an interpreter required?>	If yes, please state language: 	

Referral information:
Length/Duration of Referral: <Length/Duration of Referral>
	
Dear, 	Clinic	
Please see the Clinic & Dr list www.wch.sa.gov.au/services/az/divisions/paedm/gpreferral/documents/WCH_ClinicsDoctors.pdf 

Current Medical Problem/s Please provide information of the presenting issue and forward any pathology and x-ray reports that will assist us to determine the priority assigned to the client.
<TodaysVisit>
<VisitReason>

Past Medical History  Please provide information that will contribute to determining the priority assigned to the client.  Please note all current medications, relevant allergies and immunisations
<SelectedPMH>

Referring Clinic Details:
Referring Doctor Name: <DrName>	Provider No.: <DrProviderNo>	
Surgery Name: <Practice>	Contact no.: <UsrPhone>	
Address: <UsrAddress>		
Signature:	Date: <TodaysDate>	
Please ensure all fields have been completed, sign & date the form then fax to WCH Administration Hub on 8161 6246