Victorian Statewide Referral Form	General Practice version Feb 2023

REQUEST FOR PREGNANCY CARE CLINIC APPOINTMENT - FAX 03 4215 1383	OR
								        - E-REFER USING REFERRAL NET	
GP Referral | | Referral Date: <TodaysDate> Feedback Requested:  Yes

Referral to: Barwon Health Pregnancy Care Fax:  03 4215 1383 Service requested: <Service type> | | Referring General Practitioner: <DrName> <Practice> HPI-O: <PracHPIO> <UsrAddress> Phone: <UsrPhone>   Fax: <UsrFax> Email: <DrEmail> Provider No.: <DrProviderNo> HPI-I<DrHPII>

Consumer details:
Name:	<PtFirstName> <PtSurname>
Date of Birth:	<PtDoB>
Age:                        <PtAge>
Preferred Name/s:	<PtPrefName>
Sex:	<PtSex>
Title:	<PtTitle>
IHI: 		     <PtIHI>
ATSI:                     <PtEthnicity>

Contact Address:	<PtName>
	<PtStreet>
	<PtCity>  <PtState>    <PtPostcode>
Phone:	<PtPhoneH>
Work:	<PtPhoneWk>
Mobile:	<PtPhoneMob>
Email:	<PtEmail>

Alternative Contact: 
<Alternative Contact (Name/Ph/Relationship)>

Interpreter required: <Does the patient require an interpreter?> | | DVA Number: <PtDVANo>
Preferred language is: <If interpreter needed, which language> | | Insurance: <PtHealthIns>
Pension Card Number: <PtPensionNo> | | Medicare Number: <PtMCNo>
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:  <FormattedDate>
Patient consent to share information:  <Consent to share information>
Patient  consents to MBS bulk billing clinic:  <Consent to MBS bulk billing clinic>

Reason for patient referral: 

Age:  <PtAge> 	 Gravida:  <Gravida> 	 Para:<Para>	LNMP:<LNMP>	EDD:<EDD>	Estimated Gestation:<Estimated gestation>
Low dose aspirin: <Low dose aspirin>
Obstetric Hx: <Obstetric Hx>
Genetic Hx:  <Genetic history?>
Medical Risk Factors: <Medical Risk Factors>

Reason for referral: <Reason for Referral>
Preferred Model of Care:
<Preferred Model of Care>

Preferred clinic day: <Preferred Clinic Day - Please select up to 2>
Monday: <Monday>
Tuesday: <Tuesday>
Wednesday: <Wednesday>
Thursday: <Thursday>
Friday: <Friday>

Preferred clinic location: <Preferred Location - Please select up to 3>
Sydney Parade: <Sydney Parade>
Barwon Health North: <Barwon Health North>
Belmont: <Belmont>
Torquay: <Torquay>
Anglesea: <Anglesea>
Drysdale: <Drysdale>
HUB(UHG): <HUB  (UHG)>

Clinical Information:		<PtFirstName> <PtSurname> DOB:  <PtDoB>

Current Medication:
<RegularRx>
Allergies: <Reactions> 
Warnings: <Comment>

Past Medical History: 
<PMHAll>

Social History: 
<SocialHx> 
If smoker, smoking cessation discussed:  <If smoker, smoking cessation discussed?>

Progress Notes: 
<Visits>

Investigation Ordered:  (Please cc Pregnancy Care Clinic for all investigations ordered)
Pathology Provided By: <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?> | |

<Ix>

Ultrasound:
Dating US ordered:  <Dating US ordered?> | <Please enter US provider 1> | <Date of US>
First Trimester Combined Screening | |
NIPT | |
Second Trimester Screening | |
Genetic Carrier Screening | |
Morphology US ordered:  <Morphology US ordered?> | <Please enter US Provider 3> |

Last CST:
Has a Cervical Screening Test been performed in last 5 years?  <Has CST been performed in last 5 years?> | <Please Enter Pathology Provider 2> | <Date of  CST>

Patient Name: <PtSurname>, <PtFirstName>  DOB:  <PtDoB>

GP Referral:  <DrName>,  Date of Referral:<TodaysDate>        Patient: <PtFullName>,  DoB: <PtDoB>                 	Page