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 & Bacchus Marsh hospital (Dr Lauren De Luca- Head of Unit)	Fax: 9055 2125	

Patient Details				Referring Doctor Details	
First Name: 	Patient Demographics.First Name	Last Name:	Patient Demographics.Surname>	Name:  Treating Doctor.Name	
Previous last name:	Previous last name			Practice Name: Practice.Name	
Date of birth:	Patient Demographics.DOB			Practice address: Treating Doctor.Address	
Address:	Patient Demographics.Address			Suburb: Treating Doctor.Suburb	Postcode: Treating Doctor.Postcode	
				Ph: Treating Doctor.Phone	
Suburb:	Patient Demographics.Suburb	Postcode	Patient Demographics.Postcode	Fax:  Treating Doctor.Fax	
Home phone	Patient Demographics.Phone (Home)>	Mobile	Patient Demographics.Phone (Mobile)	Provider number: Treating Doctor.Provider Number	
Medicare no.:	Patient Demographics.Medicare Number			Date: Miscellaneous.Date	
					
Interpreter required:	Interpreter Required	Specify language:	Interpreter Languag	Disabilities or special needs
Disabilities or SN
Disabilities-details	
Does patient identify as Aboriginal or Torres Strait Islander	Identify				

WH only: Has the patient requested a homebirth?  Home birth	

Shared care
Patient would like shared care?  Shared care	
I/My practice is able to provide shared care to the patient:  Practice shared care	
Nominate suggested shared care practitioner: shared prac	

Current Obstetric History
LNMP: 	LNMP	Estimated delivery date: 	Pregnancy.EDC
Gravida: 	Gravida	Parity: 	Parity	Known multiple pregnancy: 	Known multiple preg
Height: 	Height (cm) cm 	Weight: 	Weight (kg)  kg	BMI*: BMI	*must be included to enable triage and booking

Tests/investigations (please attach results to referral if available or fax when complete to DjHS 9746 0668, 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	Does patient have a previous birth history (attach to referral)	¨  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):
Clinical Details.Medications - Current PRN

Allergies
Clinical Details.Allergies

Other Relevant Information
Other  Information

Investigations
Clinical Details.Result List (Selected)

Doctor’s signature:		Date:	Miscellaneous.Date	

Appointment details will be sent to referring GP and patient.
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This facsimile transmission is intended for the exclusive use of the person or hospital to which it is addressed and may contain information that by law is privileged or confidential. If the reader of the facsimile transmission is not the intended recipient, you are hereby notified that any disclosure, distribution of copying of this transmission is prohibited by law, and the contents must be kept strictly confidential. If you have received this transmission in error, kindly notify us immediately and return the original to us at the above address.