eConsult Online Advice Form – THHS Dermatology

Referring doctor's details

Name*

First Last

Provider number*

Contact number

Email*

Enter Email Confirm Email

Position

Position other

Practice/Facility details

Requesting facility name*

(e.g. clinic or hospital)

Queensland Health facility - Townsville HHS catchment area
Queensland Health facility - Mackay HHS catchment area
General practice within Townsville HHS catchment area
General practice within Mackay HHS catchment area
Other - Not Listed Above

QH facility - Townsville HHS catchment area*

from North Queensland

QH facility - Mackay HHS catchment area*

General Practices within Townsville HHS catchment*

General Practices within Mackay HHS catchment*

Practice name

Practice address

Street Address Suburb State Postcode

Practice email

Enter Email Confirm Email

Care type

select category of care provided for patient at time of this referral

Care type other

Patient details

Patient name*

First Last

Patient URN for THHS (if known)

Patient gender*

Male
Female
Other (please specify)

Other gender*

Patient date of birth*

Patient address*

Street Address Suburb State Postcode

Patient contact number*

Is the patient of Aboriginal or Torres Strait Islander origin

Yes
No
Not specified

Issue of concern and reason for referral

Diagnosis (if known) or problem (if condition is undiagnosed)*

Reason for referral (what specific information would you like about this case?)*

Advice regarding management
Opinion regarding diagnosis and management
Other (please specify)

Other request reason

History of presenting complaint

Duration of problem and description of how condition has evolved

Associated symptoms

(if none, please note "nil")

Other relevant information including disease impact

If the disease has a significant negative impact on the patient’s physical condition, quality of life or psychological wellbeing please specify how and to what extent (if none, please note "nil")

Hidden

Disease impact (optional)

If the disease has a significant negative impact on the patient’s physical condition, quality of life or psychological wellbeing please specify how and to what extent

Background information

Past medical history*

(if none, please note "nil")

Current medicines*

(Please provide a list of medicines your patient is currently taking. If none, please note "nil")

Allergies*

Nil known drug allergies
Other (please specify)

Other allergies*

Investigations (please include relevant results)

Please note, guiding information about relevant investigations can be found on Health Pathways (https://townsville.communityhealthpathways.org). You may attach a PDF document including your patient’s investigations below, if preferred.

Examination findings

Patient images, can be uploaded at the bottom of page below.

Note the site(s) affected, and skin changes seen

Management

Note dose, frequency, duration, and response.

Current treatments

Previous treatments

Hidden

Psycho-social issues

Hidden

Other psycho-social issues (optional)

Please note any other psychosocial issues relevant to your patient’s condition and care.

Photos and additional documents

Please note: only image (.jpg, .jpeg and .png) and PDF files are accepted. Please attach no more than 10 attachments, totalling 9MB.

If uploading multiple photos and documents, make sure that file names are different.

Drop files below or click on the Select files to upload from your file system

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 9 MB, Max. files: 10.

Consent Attachments*

I confirm that I have obtained patient consent (or consent of the patient’s substitute decision maker) for requesting this service and for the capture and uploading of the attached images.*

Consent Medical Record*

I have advised the patient (and/or their substitute decision maker) that the information and images in this request will be added to the patient’s electronic medical record at Townsville University Hospital. If a medical record does not exist for the patient, one will be created for them.*

patientConsentResearch

The patient (and/or their substitute decision maker) has given their consent for these images to be used for education and/or research purposes.

Security

Please ensure all required attachments have been successfully uploaded before submitting your eConsult Advice Request

THHS Dermatology eConsult Online Advice Form

Referring doctor's details

Practice/Facility details

Patient details

Issue of concern and reason for referral

History of presenting complaint

Background information

Examination findings

Management

Psycho-social issues

Photos and additional documents