Mercy Hospital for Women
Maternity Referral		
Referral Date: 	<<Miscellaneous:Date (short)>>	

Fax number for all referrals: 8458 4205	Outpatient enquires: 8458 4111

Provided this form is complete, it constitutes a valid referral to Mercy Hospital for Women

Patient Details
Last/Family Name: 	<<Patient Demographics:Surname>>	FirstName:  	<<Patient Demographics:First Name>>	
Previous last name: 	<<Previous last name>>	Sex:: 	<<Patient Demographics:Gender>>	
Date of birth:  	<<Patient Demographics:DOB>>	ATSI status: 	<<ATSI Status>>	
Address:  	<<Patient Demographics:Address>>	Home telephone No.:  	<<Patient Demographics:Phone (Home)>>	
Suburb:  	<<Patient Demographics:City>>	Mobile number:  	<<Patient Demographics:Phone (Mobile)>>	
Postcode:  	<<Patient Demographics:Postcode>>	Email:  	<<Patient Demographics:E-mail>>	
NOK/Carer: 	<<Patient Demographics:Next of Kin>>	Preferred contact method:  <<Preferred contact method>>	
NOK relationship:  	<<Patient Demographics:Next of Kin Relationship>>	Medicare no.:  	<<Patient Demographics:Medicare Number>>	
NOK contact No.:  	<<Patient Demographics:Next of Kin Phone>>	Pensioner/Concession/Health/DVA No.:  <<Pensioner/Concession/Health/DVA No.>>	
Country of origin:  	<<Patient Demographics:Country of Birth>>	Cultural considerations:	<<Cultural considerations>>	
Interpreter required:  	<<Interpreter required>>	Specify language:  <<Specify language (interpreter)>>	
Previous Mercy patient: <<Previous Mercy patient>>	Mercy UR Number (if known):  <<Mercy UR Number (if known)>>	
The patient has agreed to the referral and the sharing of their personal and health information with the health service:  <<Pt agreed to referral and personal info. sharing>>	

Referring Doctor Details
Referring Doctor:	<<Doctor:Name>>	Provider number:	<<Doctor:Provider Number>>	
Practice Name:	<<Practice:Name>>	
Practice Address:	<<Doctor:Address>>	
Suburb:	<<Doctor:City>>	
Postcode:	<<Doctor:Postcode>>	Phone No:	<<Doctor:Phone>>	
Email:	<<Doctor:E-mail>>	Fax:	<<Doctor:Fax>>	
Preferred method of communication:	<<Preferred contact method>>	

Patient’s usual GP (if not the same as referring doctor)	
Name:	<<Patient’s usual GP (if not referring doctor)>>	Clinic:	<<Pt’s usual Clinic (if not the same as referring doctor)>>	

Shared Care
I/My practice is able to provide shared care to the patient:  	o  Yes   o  No
Please nominate suggested shared care practitioner:  ....................................	 Comment:	

Medications: (including vitamins and supplements)	Allergies
<<Clinical Details:Medication List>>	<<Clinical Details:Allergies/Adverse Reactions>>	

Tests/investigations (please attach results to referral if available or fax when complete to relevant hospital)
Required tests:
FBE, Hb electrophoresis, Blood group and antibodies, Rubella, Hepatitis B/C, HIV, Syphilis, MSU

Tests to consider:
Dating ultrasound, chlamydia, morphology scan, ferritin, Thalassemia testing
Early GTT (to be completed after 12 weeks) if previous GDM, PCOS, BMI >35, family history of diabetes, previous large baby >4500g

Please provide results and/or provider  _____________________________________________________________

Aneuploidy Screening (should be discussed and offered to all women irrespective of age)

Patient has decided to have aneuploidy screening 	o  Yes o  No

If yes: please provide results and/or provider_________________________________________________________
If the required investigation/test results are not attached the referral will not be accepted by Mercy Health	
Current Obstetric Histroy
LNMP:	<<Clinical Details:LNMP>>		Estimated delivery date: 		
Gravida:	<<Clinical Details:Gravida>>	Parity:	<<Clinical Details:Parity>>	Known multiple pregnancy:	o  Yes o  No
	
Height:	<<Height (cm)>> cm	Weight:	<<Weight (kg)>> kg	BMI*:	<<BMI>>	*must be included to enable triage and booking	
Past Obstetric History: o  Not applicable - primigravida    o  Not applicable - no relevant past obstetric history 
Previous stillbirth 	o  Yes 	Gestational Diabetes	o  Yes 	
Previous fetal abnormality
(specify):	o  Yes 	Previous HDIP/HELLP syndrome or severe pre-eclampsia	o  Yes	
Mid trimester loss OR miscarriage x3 or more	o  Yes	Obstetric Cholestasis	o  Yes	
Preterm birth <37/40 (gestation) _______	o  Yes	Maternal red cell antibodies	o  Yes	
IUGR or <2800g at term	o  Yes	PPH >1000mls	o  Yes	
Cervical cerclage	o  Yes	Previous Neonatal Alloimmune Thrombocytopenia	o  Yes	
Placental abnormalities/abruption	o  Yes	Perinatal psychosis	o  Yes	
Previous caesarean  Number (if yes): _______	o  Yes			
Risk factors relevant to pregnancy: o  Not applicable - no relevant risk factors
Smoking in the last 12 months	o  Yes	Diabetes pre-pregnancy	o  Yes	
Alcohol and other drugs (specify)	o  Yes	Thalassaemia	o  Yes	
Psychiatric disorders 	o  Yes	Haematological/Coagulation disorder e.g. sickle cell	o  Yes	
Family history of genetic disease/anomalies
(specify): __________________	o  Yes	Other endocrine disorder
(specify): ______________	o  Yes	
Heart Disease	o  Yes	Hep B carrier or Hep C	o  Yes	
Hypertension/or on medication	o  Yes	Infectious disease e.g. HIV	o  Yes	
Respiratory Disorder including severe asthma	o  Yes	Current malignancy	o  Yes	
Gastrointestinal/liver disorder	o  Yes	Previous chemotherapy	o  Yes	
Renal Disorder	o  Yes	Uterine anomalies/fibroids	o  Yes	
Neurological Disorder e.g. epilepsy	
o  Yes	

Rheumatologic Disorder e.g. SLE	
o  Yes	

	Uterine/cervical surgery e.g. cone biopsy/LLETZ procedure	o  Yes	

Other relevant information (eg management to date, current services, impact of the problem on the patient):
<<Other relevant information>>	

Doctor’s signature: 								Date:  <<Miscellaneous:Date (short)>>
Appointment details will be sent to referring GP and the patient.