REQUEST FOR PREGNANCY LOSS ON USS (EPAS) APPOINTMENT 
FAX:  4215 2086 					
GP Referral
		Referral Date:<<Miscellaneous:Date (long)>>

Feedback Requested:  Yes	

Referral to: Barwon Health 
Early Pregnancy Assessment Service (EPAS)
[ DEPT: EPAS ]
 
Phone: 03 4215 2060
Fax: 03 4215 2086
		Referring General Practitioner:
<<Doctor:Name>> 
<<Practice:Name>>
<<Practice:Address>>
HPI-O: <<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: 

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>>	

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

Reason for patient referral: 
<<Reason for Referral ( ONLY for listed conditions)>>
Relevant Medical Hx: 
<<Relevant Medical Hx>>

Direct referral TO EPAS NOT AVAIALBLE FOR:
 <<Direct referral to EPAS NOT AVAILABLE FOR>>
 ---------------------------------------------------------------------------------------------------------------------------------
LNMP:  <<LNMP >>  Gravida: <<Gravida>>  Para: <<Para>>  Blood Group:  <<Blood Group>>
USS undertaken:  <<USS undertaken>>
Warnings: <<Clinical Details:Warnings>>

Allergies: <<Clinical Details:Allergies>> 

Current Medication:
<<Clinical Details:Medication List>>
Social History:
 <<Clinical Details:Social History>> 
<<Clinical Details:Smoking>>
Past Medical History: 
<<Clinical Details:History List>>
 ---------------------------------------------------------------------------------------------------------------------------------
Progress Notes: 
<<Summary:Progress Notes (Selected)>>

Investigation Results:
<<Summary:Investigation Results (Selected)>>

Did the HealthPathways website assist you in the assessment, management or referral of your patient? <<Did HealthPathways assist in Ax Mx referral of pt?>>	

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