MEDICAL OBJECTS ID: HM4101000R8

Patient Details
Re: <PtFullName>
Given Names: <PtFirstName> <PtMidName>
Surname: <PtSurname>
DOB: <PtDoB>
Address: <PtAddress>
Ph: <PtPhoneH> (h), <PtPhoneWk> (w), <PtPhoneMob> (m)
Preferred Contact:  <Preferred Contact>
Please advise all patients to bring their Medicare card when presenting to the Mater. Medicare ineligible patients will incur a fee for appointments / treatment provided which is payable on presentation. Insurance Provider and Policy Number must be provided before bookings can be processed.
Medicare No: <PtMCNo> <PtMCLine> Exp: <PtMCExpiry>
Insurance Provider: <Insurance Provider>  Policy Number: <Policy Number>
Next of Kin: <Next of Kin> Contact Ph: <Next of Kin Contact Ph>
Special Needs: <Special Needs e.g carer>
Does this patient identify as being Aboriginal and/or Torres Strait Islander? <Does she identify as ATSI?>
Does this patient identify as having a refugee background?          <Does she have a refugee background?>
<PtFirstName> requires an interpreter: <Requires an interpreter>
She speaks the following language(s) other than English: <Languages other than English spoken>	

This referral is for an initial consultation with a Doctor for the planning and co-ordination of care for this pregnancy. Women will be subsequently offered a choice of appropriate models of care. To improve efficiency and reduce waiting times, this named referral will be shared with other specialists. The consultation may be bulk-billed to Medicare Australia with NO out of pocket expenses for this patient.

Dear Dr Michael Beckmann (Director, Mother Babies and Women's Health Services)

Thank you for seeing <PtFirstName> for care during her pregnancy. Her LNMP was the <LMP> and her EDC is the <EDC>. She is <Parity>. 
Height, Weight and BMI: 
<Observations>   
This patient is high risk and requires early assessment? <This patient is high risk and requires and early assessment?>
If "Yes", specify details: <If high risk, please specify details>

Past genetic, medical, surgical, obstetric history:
<ObstetricHx>
<SelectedPMH>

Current Medications: 
<CurrentRx>
Allergies: 
<Reactions>

Models of care
I have discussed models of care and this woman would like:
GP Shared Care? <GP Shared Care?>
I have completed the MMH alignment program: <I have completed the MMH alignment program?>
Midwifery Care? <Midwifery Care?>
Midwifery Group Practice? <Midwifery Group Practice?>
Second choice if Midwifery Group Practice full? <Second choice if Midwifery Group Practice full?>

Relevant Investigations: 
Pathology Service Provider: <Pathology Service Provider>
Pap Smear Up to Date: <Pap Smear Up to Date> Result: <PapSmears> Date Completed: <Date Pap Smear completed?>
1. Down Syndrome screening discussed: <Downs Syndrome Screen Discussed> 
Accepted: <Downs Syndrome Screen Accepted>
Referral Given: <Down Syndrome Referral Given?>
Copy given to womam: <Copy given to woman>
2. OGTT for BMI > 35, previous GDM, macrosomic baby, PCOS? <OGTT for BMI>35, previous GDM, macrosomic baby, PCOS?>  
3. OGTT, E/LFT, Protein / Creatinine Ration for woman with BMI > 35: <OGTT, E/LFT, Protein/Creatinine Ration for woman with BMI>35>
4. 18/40 Morphology Ultrasound Ordered: <18/40 Morphology Ultrasound Ordered>
5. FBC: <FBC ordered>
6. Rubella Serology: <Rubella Serology ordered>
7. Urine M/C/S: <Urine M/C/S ordered>
8. HIV: <HIV ordered>
9. Syphilis Serology: <Syphilis serology ordered>
10. Blood Group and Antibody: <Blood Group & Antibody>
11. Hepatitis B Serology: <Hepatitis B serology ordered>
12. Hepatitis C Serology: <Hepatitis C Serology>

Thank you for your advice and management.

Yours sincerely,

<DrName>
<DrAddress>	
Phone: <DrPhone>  Fax: <DrFax>
Provider No.: <DrProviderNo>
Email: <DrEmail>
<TodaysDate>

Mater Staff Use Only
Date Received:       /       /         Age:                      EDC:                             Current Gestation:
r Referral Accepted
r Referral Declined 
Reason for decline:    r Closed to EDC       r Northside          r Out of Area       r Other:                    
                                  r GP Notified  Date Sent:      /      /          r Woman Notified  Date Notified:       /       /

r Midwifery History  K                r ANC         r Inala           r CHAMP      r MGP
                                                     r YMC        r Indigenous   r Diabetic      r Refugee  

r 1st Obstetric Visit K              

r Medicare eligible                   r Medicare ineligible AND Insured   Sent to billing office:       /       /
                             r Medicare ineligible, NOT Insured   Sent to billing office:       /       /     
Notes:

Midwife Signature:                                 Date:       /       /                                                                                                 	

Relevant Investigation Results:
<Ix>