REQUEST FOR GYNAE CHOICES APPOINTMENT - 					FAX 03 4215 0806					
GP Referral
		Referral Date: <<Miscellaneous:Date (long)>>

Feedback Requested:  Yes	

Referral to:
Barwon Health Gynae Choices (TOP)
Phone: 03 4215 0777
Fax: 03 4215 0806
Service requested: <<Service Requested>>	 		Referring General Practitioner:
<<Doctor:Name>> 
<<Practice:Name>>
HPI-O: <<Practice:HPI-O>>
<<Practice:Address>>
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>>
IHI:                             <<Patient Demographics:IHI>>

ATSI:  <<Patient Demographics:ATSI>>		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:Medicare Number>><<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>>	

Date patient consented to referral:  <<Miscellaneous:Date>>	
Consent to share information:  <<Consent to share information>>	
Consent to MBS bulk billing clinic:  <<Consent to MBS bulk billing clinic>>	

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

Patient medically informed of choices between:
MTOP & STOP:  <<Informed of choice between MTOP & STOP>>
MTOP < 9/40: <<MTOP < 9/40>>                        STOP <12/40:  <<STOP < 12/40>> 

MTOP dating ultrasound results attached:  <<MTOP dating ultrasound results attached>>	

Clinical Information:		<<Patient Demographics:First Name>> <<Patient Demographics:Surname>> DOB:  <<Patient Demographics:DOB>>

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

LNMP:  <<LNMP if known>>
Gestation Estimate: <<Gestation estimate>>
Blood Group:  <<Blood Group>>
BHCG:  <<BHCG results attached>>
Urine Chlamydia result attached:  <<Urine chlamydia result attached>>
Urine Gonorrhoea result attached:  <<Urine gonorrhoea result attached>>	

Warnings: <<Clinical Details:Warnings>>
Allergies: <<Clinical Details:Allergies>> 
Social History: <<Clinical Details:Social History>> 
Smoking Hx:  <<Clinical Details:Smoking>>
If smoker, has smoking cessation been discussed?: <<If smoker, has cessation program been discussed?>>	

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

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

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

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

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