RAPID Nurse Referral - Queensland Positive People

Nurse Practitioner Clinic

This below referral is to be completed by a qualified healthcare professional.

To refer yourself for assessment or treatment, contact the Nurse Practitioner Clinic on 07 3013 5561

Company

This field is for validation purposes and should be left unchanged.

Referrer's Name(Required)

First Last

Referrer's Position(Required)

Referrer's Service/Organisation(Required)

Referrer's Email Address(Required)

Email Address Confirm Email Address

Referrer's Phone Number(Required)

Client Legal Name(Required)

First Middle Last

Client Date of Birth(Required)

Client Gender(Required)

Describe Client Gender(Required)

Does the client have Medicare?(Required)

Yes

Medicare Number(Required)

Medicare IRN(Required)

Medicare Expiry(Required)

Client Address(Required)

Street Address Address Line 2 Suburb State/Territory Postcode Country

Client Phone Number(Required)

Client Email Address

Reason for Referral(Required)

Medical History

Medications

Please attach any/all relevant information/documents

Examples include: Imaging, pathology results, letters

Drop files here or

Max. file size: 256 MB.

Upon submission, would you like to be emailed a PDF copy of this referral for your records?

Yes