Victorian Statewide Referral Form					General Practice Version Feb 2023

REQUEST FOR PREGNANCY CARE CLINIC APPOINTMENT     -FAX 03 4215 1383 
									  -E-REFER USING REFERRAL NET

GP Referral | | Referral Date: Miscellaneous.Date Feedback Requested:  Yes

Referral to: Barwon Health Pregnancy Care Clinic Fax: 03 4215 1383 Service requested: Service Requested | | Referring General Practitioner: Treating Doctor.Name Address: Practice.Address Ph: Practice.Phone Fax: Practice.Fax Provider No.: Treating Doctor.Provider Number

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: Alternative

Interpreter required:Interpreter | | DVA Number: Patient Demographics.DVA Number
Preferred language is: Language | | Insurance: Patient Demographics.Health Fund Member Number
Pension Card Number: Patient Demographics.Pension Number | | Medicare Number: Patient Demographics.Medicare 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 State Referral Criteria, patient assessment, management and referral. 
HealthPathways

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

Reason for patient referral

Gravida: Gravida Para: Para  LNMP: LNMP  EDD: EDD  Estimated gestation: Est gestation
Low dose aspirin: Low dose aspirin 
Obstetric Hx: Obstetric Hx

Genetic Hx: Genetic Hx
Medical Risk Factors:  Risk factors

Reason for patient referral: 
Referral reason

Preferred Model of care:  Preferred Models of 

Preferred Clinic Day: Preferred Clinic Day
Monday: Monday
Tuesday: Tuesday
Wednesday: Wednesday
Thursday: Thursday
Friday: Friday

Preferred Clinic Location:Preferred Clinic Loc
Sydney Pde: Sydney Pde
Barwon Health North: Barwon Health North
Belmont: Belmont
Torquay: Torquay
Angelsea: Anglesea
Drysdale: Drysdale
HUB: (UHG): HUB (UHG)

Social History:
Clinical Details.Social History
If smoker, smoking cessation discussed:  Cessation smoking
Substance use: Substance use

Current Medication:
Clinical Details.Medications Current Regular
Allergies: Clinical Details.Allergies
Warnings: Clinical Details.Warnings

Social History:
Clinical Details.Social History
Clinical Details.Smoking  Clinical Details.Alcohol (Summary)

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

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

Investigation Ordered:  (Please CC Pregnancy Care Clinic for all pathology ordered)
Pathology provided by:Pathology Provider

FBE ordered? FBE | Blood Goup ordered? Blood grp
Antibodies? Antibodies | Hepatitis B ordered? Hepatitis B
Hepatitis C ordered? Hepatitis C | HIV ordered? HIV
RPR ordered? RPR | Rubella ordered? Rubella
Varicella ordered? Varicella | MSU ordered? MSU
Vitamin D ordered? Vitamin D |
Clinical Details.Result List (Selected)

Ultrasound:
Dating US ordered: Dating US ordered | US provider1 | Date1
First Trimester Combined Screening | |
NIPT | |
Second Trimester Screening | |
Genetic Carrier Screening | |
Morphology US ordered: Morphology US ordere | US provider2 |

Last Cervical Screening Test:
Has a Cervical Screening Test been performed in last 5 years? CST been performed | Pathology provider2 | Date2

GP  Referral Treating Doctor.Name  Miscellaneous.Date  Pt:Patient Demographics.Full Name DOBPatient Demographics.DOB	                                                                                                                                   pg