REQUEST FOR PREGNANCY CARE CLINIC APPOINTMENT - FAX 03 4215 1383	OR
								    - E-REFER USING REFERRALNET

GP Referral	Referral Date: <<Miscellaneous:Date (long)>>
Feedback Requested:  Yes	

Referral to:
Barwon Health Pregnancy Care Clinic
 (Dr Aik Lyn Tan)
Fax:  03 4215 1383

Service requested: Pregnancy Care Clinic			Referring General Practitioner:
<<Doctor:Name>> 
<<Practice:Name>>
<<Practice:Address>>
<<Practice:HPI-O>>
Phone: <<Practice:Phone>>   Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>
HPI-I:<<Doctor:HPI-I>>	

Consumer details:
Name: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of Birth:	<<Patient Demographics:DOB>>
Age:                        <<Patient Demographics:Age>>
Preferred Name/s:	<<Patient Demographics:Greeting>>
Sex:	<<Patient Demographics:Sex>>
Title:	<<Patient Demographics:Title>>
Pt IHI:<<Patient Demographics:IHI>>
	Contact Address:	<<Patient Demographics:Full Name>>
	<<Patient Demographics:Address>>
	<<Patient Demographics:City>>  <<Patient Demographics:State>>    <<Patient Demographics:Postcode>>
Phone:	<<Patient Demographics:Phone (Home)>>
Work:	<<Patient Demographics:Phone (Work)>>
Mobile:	<<Patient Demographics:Phone (Mobile)>>
Email:	<<Patient Demographics:E-mail>>
Alternative Contact: 
<<Alternative Contact (Name/Ph/Relationship)>>	
Interpreter required: <<Does the patient require an interpreter?>>	  DVA Number: <<Patient Demographics:DVA Number>>	
Preferred language is: <<If interpreter needed, which language>>	  Insurance: <<Patient Demographics:Health Insurance>>	
Pension Card Number: <<Patient Demographics:Pension Number>>	  Medicare Number: <<Patient Demographics:Medicare Number>>	
Mother Aboriginal or Torres Strait Islander:  <<Mother Aboriginal or Torres Strait Islander?>>	  Baby Aboriginal or Torres Strait Islander:  <<Baby Aboriginal or Torres Strait Islander?>>	

Date patient consented to referral:  <<Miscellaneous:Date (short)>>	
Consent to share information:  <<Consent to share information>>	
Consent to MBS bulk billing clinic if available:  <<Consent to bulk billing clinic>>	

HealthPathways provides guidance in patient assessment, management and referral. 	<<HealthPathways for guidance in Mx Ax referral>>	

Clinical Information:

Reason for patient referral: 
<<Reason for Referral>>

Pt Age: <<Patient Demographics:Age>>  
Gravida:  <<Gravida>>  
Para:  <<Para>>  
LNMP:  <<LNMP>>  
EDD:  <<EDD>>  
Estimated gestation:  <<Estimated gestation>>
Periconceptual folic acid:  <<Periconceptual folic acid given ?>>
First trimetser folic acid:  <<First trimetser folic acid been given?>>
Recent PHx Medications list review:  <<Recent PHx Medications list review?>>
CS Hx: <<Previous Caesarean Section? >>
Number of CS: <<If Yes, how many previous CS?>>
Risk factors:  <<Risk factors?>>
Genetic Hx:  <<Genetic history?>>

I am credentialed for the current triennium with BH for shared antenatal care:    <<I am credentialed for shared antenatal care?>>
I am willing to participate in shared antenal care if indicated: <<GP willing to participate in shared antenatal care?>>
Reason GP shared care is important to this patient:  <<Reason why GP shared care is important to Pt>>	
  
Warnings: <<Clinical Details:Warnings>>
Allergies: <<Clinical Details:Allergies>> 
Social History: <<Clinical Details:Social History>>
Smoking:  <<Clinical Details:Smoking>>
Smoking cessation strategy discussed:  <<Smoking cessation strategy discussed>>	

Current Medication:
<<Clinical Details:Medication List>>	

Past Medical History: 
<<Clinical Details:History List>>	

Progress Notes: 
<<Summary:Progress Notes (Selected)>>	

Investigation Ordered:  (Please cc Pregnancy Care Clinic for all pathology ordered)

Pathology Provided By: <<Please Enter Pathology Provider>>
FBE:  <<FBE ordered?>>	Blood Group:  <<Blood Group ordered?>>	
Antibodies: <<Antibodies?>> 	Hep B:  <<Hepatitis B ordered?>>	
Hep C: <<Hepatitis C>>	HIV:  <<HIV ordered?>>	
RPR:  <<RPR ordered?>>	Rubella:  <<Rubella ordered?>>	
Varicella:  <<Varicella ordered?>>	MSU:  <<MSU ordered?>>	
Vitamin D: <<Vitamin D ordered?>>		

Patient Name: <<Patient Demographics:Surname>>, <<Patient Demographics:First Name>> DOB: <<Patient Demographics:DOB>>

<<Summary:Investigation Results (Selected)>>

Ultrasound:

Dating US ordered:  <<Dating US ordered?>>	 <<Please enter US provider 1>>	<<Date of US?>>	
Downs syndrome screening discussed:  <<Downs syndrome screening discussed>>			
T1 Screening US Ordered: <<T1 Screening US Ordered?>>	  <<Please enter US provider 2>>	 <<Date of T1 Screening US?>>	
Morphology US ordered: <<Morphology US ordered?>>	 <<Please enter US provider 3>>	<<<Date of Morphology US?>>	

Last Pap Testing:

Has a Pap test been performed in last 24/12?: <<Has a Pap smear been performed in last 24/12? >>	 <<Please Enter Pathology Provider 2>>	 <<Date of Pap Smear?>>	
Details of Pap test:<<Clinical Details:Pap Smears>>