GNEw9010 o o  SERV0010 GNEwGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010@8@q@@@@T@@@@7@o@@@GNEweparator 4D_enable 4D_checkableGNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010GNEw<\GNEw9010GNEweparator 4D_enable 4D_checkableGNEw9010 Page ]Z0*xxxxxxxxxxxxxxxPage number Re: ] JBO5& DOB: ] JBO5 TRPweparator 4D_enable 4D_checkableTRPw0010IRPXIRPUVT$m@dXXIRPWNorth Lakes - Admin Room on LU 4dXXA4+FNIwDoConfirmq@1FNIw0010 \MRPwMRPw4010/= +e+H++HHH,?XIPw XIPw301BORPweparator 4D_enable 4D_checkablePRPw1010  TNFw TNFw0010Times New RomanArialSymbolHelvetica-Bold WingdingsCalibriCambriaTimes New Roman CETimes New Roman CyrTimes New Roman GreekTimes New Roman TurTimes New Roman (Hebrew)Times New Roman (Arabic)Times New Roman BalticTimes New Roman (Vietnamese) Calibri CE Calibri Cyr Calibri Greek Calibri TurCalibri BalticCalibri (Vietnamese) Cambria CE Cambria Cyr Cambria Greek Cambria TurCambria BalticCambria (Vietnamese) Arial NarrowLTSwNormalor 4D_enable 4D_checkableLTSw0010PRPw1010  TTSw1010ABATw2010Times New RomanMetro North Hospital & Health Service Central Patient Intake PALLIATIVE CARE REFERRAL FORM  MNHHS Central Patient Intake, Aspley Community Health Centre, 776 Zillmere Road, Aspley, Qld, 4034. Phone 1300 364 938 Fax: 1300 364 952  Secure electronic transfer to Metro North Central Patient Intake (MQ40290004P) ============================================================================== Specialty referred to:  Type of service: Referral date: ]zzlJBO5ZNKOT@NRTX& Show_CurrentDatew@ An assessment and triage process by the palliative care team will aim to develop a management plan involving services that are appropriate to the patient s circumstance. Incomplete referrals or absence of essential information will delay the process. If the matter is URGENT or OUTSIDE BUSINESS HOURS, please telephone switchboard and ask for the Palliative Care Doctor on call. ============================================================================== Patient Details Re: ] JBO5& @DOB: ] JBO5 >](C](CCC>Age: ] JBO5% @Sex: ] JBO5 >(\#C(\#CCC>AACC Medicare Number: ] JBO5' Address: ] JBO5 ] JBO5H ] JBO5 ] JBO5, ] JBO5+ Phone (hm): ] JBO5 >< wB< wBCC>AACCPhone (mob): ] JBO5J @Preferred mailing address: >(C(CCC>>CCCC>>CCCC>>CCCC>>CCCC>Lives alone: @Aboriginal or Torres Strait Islander origin: Interpreter required: >> >If yes, what is the preferred language: Alternative contact name: Alternative contact address: Alternative contact phone: Relationship to patient: > Alternative contact to be present at assessment: ============================================================================== Reason for referral Life limiting illness Primary diagnosis (inc date): Significant Comorbidities: Detailed history of comments: Location of patient: Ideal response time: Name of the consultant case discussed with: ============================================================================== Past History Relevant Medical and Surgical History:  Current medications: ]ddVJBO5DNKOT@NRTX Show_Scriptsw Allergies: ]ffXJBO5FNKOT@NRTX Show_Allergies.Relevent Investigations: Details of additional documents faxed eg (EPOA)? @@ @D@h@@@@@@@@d@@@ Do you consider the patient to be frail: Yes__ No__ @@ @D@h@@@@@@@@d@@@If yes, please provide the Clinical Frailty Score: 1 Very Fit __> >4 Vulnerable __ >7 Severely Frail __ 2 Well __ >> 5 Mildly Frail __ >>>>>8 Very Severely Frail __ 3 Managing Well __ >6 Moderately Frail __ >9 Terminally Ill __  Clinical Frailty Tool:  www.bit.ly/cfscore ============================================================================== Referring Doctor Details > Doctor: ] JBO5  Provider No. ] JBO5 ! Doctor Address: ]vvhJBO5VNKOT@NRTX" Write_HandleField  Phone: ] JBO5 Fax: ] JBO5 Patient s Usual G.P. (if different from referrer): Verification  Signed: ] JBO5  MNHHS Palliative Care Referral v6.2 Genie180701 ==============================================================================  Metro North Palliative Care Contact Details Redcliffe / Caboolture / Kilcoy Palliative Care Service @r@>BBBBPhone: 07 3883 7777(Urgent medical referrals  ask for PCU Dr on call). >AACCFax: 1300 364 952 @@r The Prince Charles Hospital @s@>BBBBPhone: 07 3139 4000(Urgent medical referrals  ask for PCU Dr on call) >AACCFax: 1300 364 952 @@s Royal Brisbane and Women s Hospital Phone: 07 3646 8111 Inpatient referrals only(Urgent medical referrals  ask for PCU Dr on call) Domiciliary Palliative Care @ >(B(B(B(BPhone: 1300 658 252 (CRU enquiries) >(B(B(B(BFax: 1300 364 952 (CPI Fax) or Fax: 3049 1260 (weekend domiciliary referrals only) @  For Services outside of Metro North @Palliative Care Helpline > IC ICCCPhone: 1800 772 273 Paediatric Palliative Care Service (under 16) >BBCCPhone: 1800 249 648