Victorian Statewide Referral Form				General Practice Version Jul 2019

REQUEST FOR GYNAE CHOICES (TOP) APPOINTMENT - FAX 03 4215 0806
GP Referral | | Referral Date: Miscellaneous.Date Feedback Requested:  Yes

Referral to: Barwon Health Gynae Choices Phone: 03 4215 0777 Fax: 03 4215 0806 Service Requested:  Service Requested | | Referring General Practitioner: Treating Doctor.Name Address: Practice.Address HIP-O: Ph: Practice.Phone Fax: Practice.Fax Provider No.: Treating Doctor.Provider Number HIP-I

Consumer details:
Name: Patient Demographics.Full Name
Date of Birth:.Patient Demographics.DOB
Age:.Patient Demographics.Age
Sex: Patient Demographics.Gender
Title: Patient Demographics.Title
IHI: Patient Demographics.IHI Number
ATSI:    Patient Demographics.ATSI Status

Contact Address:
Patient Demographics.Full Name
Patient Demographics.Full Address
Tel (H): Patient Demographics.Phone (Home)
Tel (M): Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Alternative Contact:

Interpreter required: Interpreter required | |
Preferred language is: Language required | | Medicare Number: Patient Demographics.Medicare Number
Pension Card Number: Patient Demographics.Pension Number | |

Date patient consented to referral:  Miscellaneous.Date
Consent to share information:  Share information
Consent to MBS bulk billing clinic:  MBS Clinic

WestVic HealthPathways provides guidance in patient assessment, management and referral. HealthPathways

CLINICAL INFORMATION

Patient details:  Patient Demographics.Full Name Patient Demographics.DOB

Reason for patient referral: 
Referral reason

Patient medically informed of choices between:

MTOP & STOP:  Informed MTOP/STOP
MTOP < 9/40: MTOP <9/40                              STOP <12/40:  STOP <12/40

MTOP dating ultrasound results attached:  MTOP Ultrasound

LNMP: Date LNMP | BHCG:  BHCG
Gestation Estimation: Gestation estimate | Urine PCR Chlamydia:  PCR Chlamydia
Blood Group: Blood group | Urine PCR Gonorrhoea:  PCR Gonorrhoea
Warnings: Clinical Details.Warnings |
Allergies: Clinical Details.Allergies |

Current Medication:
Clinical Details.Medications Current Regular

Social History:
Clinical Details.Social History 
Clinical Details.Alcohol (Summary) 
Clinical Details.Smoking  
If yes to smoking, has cessation program been discussed?:  Smoking cessation

Past Medical History: 
Clinical Details.Problem List (Resolved) With Comments

Current Medical History:
Clinical Details.Problem List (Current) With Comments

Investigation Results:
Clinical Details.Result List (Selected)

Signed: Dr

Treating Doctor.Name

Date: Miscellaneous.Date

Barwon Health Gynae Choices Referral  Treating Doctor.Name  Miscellaneous.Date