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

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

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

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;WPTOOLSOBJ Type:0;Mode:3;Width:0;Height:0;Wrap:0;Patient’s usual GPWPTOOLSOBJWPTOOLSOBJ	Clinic:	WPTOOLSOBJ Type:0;Mode:3;Style:[[]];Width:0;Height:0;Wrap:0;WPTOOLSOBJ Type:0;Mode:3;Width:0;Height:0;Wrap:0;Patient’s usual GPWPTOOLSOBJWPTOOLSOBJ	

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

Clinical information
Gravida / Para:  Gravida / Parity	Last Cervical Screen:  Last Cervical Screen	
Allergies:  
Clinical Details.Allergies	
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
Clinical Details.Result List (Selected)	

Current medication
Clinical Details.Medications - Current PRN	

Past medical history
Clinical Details.Problem List (Current)	
Relevant social history
Clinical Details.Social History	

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

Doctor’s signature:								Date:  Miscellaneous.Date	
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.