Mercy Hospital for Women
Maternity Referral		
Referral Date: 	Miscellaneous.Date	

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.Suburb	Mobile number:  	Patient Demographics.Phone (Mobile)	
Postcode:  	Patient Demographics.Postcode	Email:  	Patient Demographics.E-mail	
NOK/Carer: 	Patient Demographics.NOK Name	Preferred contact method:  Pref contact method	
NOK relationship:  	Patient Demographics.NOK Relationship	Medicare no.:  	Patient Demographics.Medicare Number	
NOK contact No.:  	Patient Demographics.NOK Home Phone	Pensioner/Concession/Health/DVA No.:  Card No	
Country of origin:  	Country of origin	Cultural considerations:	Cult considerations	
Interpreter required:  	Interpreter required	Specify language:  Specify language	
Previous Mercy patient: Previous Mercy Pt	Mercy UR Number (if known):  Mercy UR No	
The patient has agreed to the referral and the sharing of their personal and health information with the health service:  Pt Consent	

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

Patient’s usual GP (if not the same as referring doctor)	
Name:	WPTOOLSOBJ Type:0;Mode:3;Style:[[]];Width:0;Height:0;Wrap:0;Patient’s usual GPWPTOOLSOBJ	Clinic:	WPTOOLSOBJ Type:0;Mode:3;Style:[[]];Width:0;Height:0;Wrap:0;Pt’s usual ClinicWPTOOLSOBJ	

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.Medications - Current PRN	Clinical Details.Allergies	

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:	LNMP		Estimated delivery date: 		
Gravida:	Gravida	Parity:	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 info	

Doctor’s signature: 								Date:  Miscellaneous.Date
Appointment details will be sent to referring GP and the patient.