Mercy Hospital for Women
Outpatients Referral		
Referral Date: 	<TodaysDate>	

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

Clinic requested
Specialty:  <Specialty (Clinic requested)>	Clinic Doctor (if known):  <Clinic Doctor (if known)>	

Patient Details
Last/Family Name: 	<PtSurname>	FirstName:  	<PtFirstName>	
Previous last name: 	<Previous last name>	Sex:: 	<PtSex>	
Date of birth:  	<PtDoB>	ATSI status: 	<ATSI Status>	
Address:  	<PtStreet>	Home telephone No.:  	<PtPhoneH>	
Suburb:  	<PtCity>	Mobile number:  	<PtPhoneMob>	
Postcode:  	<PtPostcode>	Email:  	<PtEmail>	
NOK/Carer: 	<PtNext of Kin>	Preferred contact method:  <Preferred contact method>	
NOK relationship:  	<PtNext of Kin Relationship>	Medicare no.:  	<PtMCNo>	
NOK contact No.:  	<PtNext of Kin Phone>	Pensioner/Concession/Health/DVA No.:  <Pensioner/Concession/Health/DVA No.>	
Country of origin:  	<PtCountry 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:	<DrName>	Provider number:	<DrProviderNo>	
Practice Name:	<Practice>	
Practice Address:	<DrStreet>	
Suburb:	<DrCity>	
Postcode:	<DrPostcode>	Phone No:	<DrPhone>	
Email:	<DrEmail>	Fax:	<DrFax>	
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)>	

Reason for patient referral / Presenting problem (or working diagnosis)
<Reason for patient referral>	

Clinical information
Gravida / Para:  <Gravida> / <Parity>	Last Cervical Screen:  <Last Cervical Screen>	
Allergies:  
<Allergies/Adverse Reactions>	
Height (cm):  <Height (cm)>	Weight (kg):  <Weight (kg)>	BMI:  <BMI>	

Relevant investigation / test results
Please attach results as per the Statewide Referral Criteria for Specialist Clinics https://src.health.vic.gov.au
If the required investigation/test results are not attached the referral will not be accepted by Mercy Health
<Ix>	

Current medication
<CurrentRx>	

Past medical history
<PMHAll>	
Relevant social history
<SocialHx>	

Other notes (e.g. current services)
<Other notes (e.g. current services)>	

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

IMPORTANT NOTICE – PRIVILEGED AND CONFIDENTIAL MESSAGE
This facsimile transmission is intended for the exclusive use of the person or hospital to which it is addressed and may contain information that by law is privileged or confidential. If the reader of the facsimile transmission is not the intended recipient, you are hereby notified that any disclosure, distribution of copying of this transmission is prohibited by law, and the contents must be kept strictly confidential. If you have received this transmission in error, kindly notify us immediately and return the original to us at the above address.
This form constitutes a valid referral to Werribee Mercy Hospital provided all requested details are complete.