Maternity Care Referral Form (v1)	
Provided this form is complete, it constitutes a valid referral to Werribee Mercy Hospital and Western Health (Joan Kirner Women's & Children's hospital and Bacchus Marsh hospital).	
		
Fax referral to:		
Werribee Mercy Hospital (Dr Jacqueline Van Dam (Head of Unit)	Fax: 8754 6710	
Western Health (Joan Kirner and Bacchus Marsh hospital  (Dr Lauren De Luca  – Head of Unit)	Fax: 9055 2125	

Patient Details				Referring Doctor Details	
First Name: 	<PtFirstName>	Last Name:	<PtSurname>	Name:  <DrName>	
Previous last name:	<Previous last name>			Practice Name: <Practice>	
Date of birth:	<PtDoB>			Practice address: <DrStreet>	
Address:	<PtStreet>			Suburb: <DrCity>	Postcode: <DrPostcode>	
				Ph: <DrPhone>	
Suburb:	<PtCity>	Postcode	<PtPostcode>	Fax:  <DrFax>	
Home phone	<PtPhoneH>	Mobile	<PtPhoneMob>	Provider number: <DrProviderNo>	
Medicare no.:	<PtMCNo>			Date: <TodaysDate>	
					
Interpreter required:	<Interpreter Required>	Specify language:	<Interpreter: Specify language>	Disabilities or special needs
<Disabilities or special needs>
<Disabilities or special needs (detail)>	
Does patient identify as Aboriginal or Torres Stait Islander	<Does pt identify as Aboriginal or Torres Strait Islander>				

WH only: Has the patient requested a home birth? <WH only: Has patient requested a homebirth?>	

Shared Care
Patient would like shared care? <Patient would like shared care>
I/My practice is able to provide shared care to the patient: <I/My Practice is able to provide shared care>	
Please nominate suggested shared care practitioner: <Please nominate suggested shared care practitioner>	

Current Obstetric History
LNMP: 	<LMP>	Estimated delivery date: 	<Estimated delivery date>
Gravida: 	<Gravida>	Parity: 	<Parity>	Known multiple pregnancy: 	<Known multiple pregnancy>
Height: 	<Height (cm)> cm 	Weight: 	<Weight (kg)>  kg	BMI*: <BMI>		

Tests/investigations 
Please attach results to referral if available or fax when complete to:   Werribee Mercy Hospital 8754 6710
                                                                                                               Western Health 9055 2125):
Required tests:
FBE, ferritin, Thalassemia testing/Hb electrophoresis, Blood group and antibodies, Rubella, Hepatitis B/C, HIV, Syphilis, MSU
Tests to consider:
Dating ultrasound, vitamin D, chlamydia, morphology scan.
Early GTT if previous GDM, PCOS, BMI >35, family history of diabetes, previous large baby >4500g

Please provide results and/or provider: ______________________________________________________________

Aneuploidy Screening	 (should be discussed and offered to all women irrespective of age)
Patient has decided to have aneuploidy screening:	¨ Yes	¨ No
If yes: please provide results and/or provider: _________________________________________________________

Past Obstetric History: ¨   Not applicable - primigravida    ¨   Not applicable - no relevant past obstetric 
	
Previous stillbirth	
¨  Yes	
Gestational Diabetes	
¨  Yes	

Previous fetal abnormality (specify	
¨  Yes	
Previous HDIP/HELLP syndrome or severe pre-eclampsia	
¨  Yes	

Mid trimester loss OR miscarriage x3 or more	
¨  Yes	
Obstetric Cholestasis	
¨  Yes	

Preterm birth <37/40 (gestation) _______	
¨  Yes	
Maternal red cell antibodies	
¨  Yes	

IUGR or <2800g at term	
¨  Yes	
PPH >1000mls	
¨  Yes	

Cervical cerclage	
¨  Yes	
Previous Neonatal Alloimmune Thrombocytopenia	
¨  Yes	

Placental abnormalities/abruption	
¨  Yes	
Perinatal psychosis	
¨  Yes	

Previous caesarean  Number(if yes): ________	
¨  Yes	

	

Risk factors relevant to pregnancy: ¨   Not applicable - no relevant risk factors 
	
Smoking in the last 12 months	
¨  Yes	

Alcohol and other drugs (specify) 	
¨  Yes	
Diabetes pre-pregnancy	
¨  Yes	

Psychiatric disorders	
¨  Yes	
Other endocrine disorder (specify)	
¨  Yes	

Family history of genetic disease/anomalies (specify)	
¨  Yes	
Thalassaemia	
¨  Yes	

Heart Disease	
¨  Yes	
Haematological/Coagulation disorder e.g. sickle cell	
¨  Yes	

Hypertension/or on medication	
¨  Yes	
Hep B carrier or Hep C	
¨  Yes	

Respiratory Disorder including severe asthma	
¨  Yes	
Infectious disease e.g. HIV	
¨  Yes	

Gastrointestinal/liver disorder	
¨  Yes	
Current malignancy	
¨  Yes	

Renal Disorder	
¨  Yes	
Previous chemotherapy	
¨  Yes	

Neurological Disorder e.g. epilepsy	
¨  Yes	
Uterine anomalies/fibroids	
¨  Yes	

Rheumatologic Disorder e.g. SLE	
¨  Yes	
Uterine/cervical surgery e.g.   cone biopsy/LLETZ procedure	
¨  Yes	

Medications (including vitamins and supplements):
<SelectedRx>

Allergies
<Reactions>

Other Relevant Information
<Other Relevant Information>

Investigations
<Ix>

Doctor’s signature:		Date:	<TodaysDate>	

Appointment details will be sent to referring GP and patient.
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