Referral Date: 	<TodaysDate>				

Maternity Care Referral Form
Provided this form is complete, it constitutes a valid referral to Djerriwarrh Health Service (Bacchus Marsh & Melton Regional Hospital), Werribee Mercy Hospital and Western Health (Sunshine Hospital).

Fax referral to:
Djerriwarrh Health Service	 (Dr Nisha Khot – Head of Unit)			Fax: 9746 0668
Werribee Mercy Hospital (Dr Jacqueline Van Dam – Head of Unit)			Fax: 8754 6710
Western Health (Dr Elske Posma – Head of Unit)					Fax: 9055 2125	

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)>	

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
<CurrentRx>	<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:	<LMP>		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 information>	

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