1. Telehealth Recipient Details
Last Name:
First Names:
UR Number:
Date of Birth:
Gender:
Unknown
Female
Male
2. Provider Clinic Details
Provider Hospital:
Provider Clinic:
Cardiology
Endocrine
Gastroenterology
General Medicine
Infectious Diseases
Neurology
Rheumatology
Respiratory Outpatients
TB Control Clinic
Other:
Providing Doctor:
Provider Clinic Phone No:
Appointment Date:
Appointment Time:
Duration:
minutes
3. Telehealth Consultation Type
Recipient Location:
Queensland Health Telehealth facility
other telehealth facility
private device (PC, tablet or phone)
Facility name:
Queensland Health facility. This can be in a QH facility with dedicated telehealth equipment, or on another device using Jabber and a QH login. Other telehealth facility. Nursing home or medical practice using non-QH telehealth device. Private Device. Personal computer, laptop, tablet or phone.
Telehealth mode:
peer to peer direct connection
virtual clinic room
Peer to Peer direct connection. Two participants only with one directly calling the other. Virtual Clinic Room. Two or more participants, all dialling into a central bridge.
4. Telehealth Consultation Details
Dial in Number:
PIN required?
No
Yes
Who is to dial in:
provider
recipient
all participants must dial in
Contact details for telehealth recipient:
Nursing support required:
none required
yes, no obs
yes, routine obs
yes, specify request