MEDICAL OBJECTS ID: HM4101000R8

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Patient Details
Re: <<Patient Demographics:Full Name>>
Surname:  <<Patient Demographics:First Name>>
Given Names:  <<Patient Demographics:Surname>>
DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Full Address>>
Ph: <<Patient Demographics:Phone (Home)>> (h), <<Patient Demographics:Phone (Work)>> (w), <<Patient Demographics:Phone (Mobile)>> (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: <<Patient Demographics:Medicare Number>> 
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?>>
<<Patient Demographics:First Name>> 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 specilaists. The consultation may be bulk-billed to Medicare Australia with NO out of pocket expenses for this patient.

Dear Dr Michael Beckman (Director, Mothers Babies and Woman's Health Services)

Thank you for seeing <<Patient Demographics:Full Name>> for care during her pregnancy. Her LNMP was the <<Clinical Details:LNMP>> and her EDC is the <<Clinical Details:EDC>>. She is G<<Clinical Details:Gravida>> P<<Clinical Details:Parity>>. 

Height:  <<Height>>  Weight: <<Weight>> BMI: <<BMI>> 
This patient is high risk and requires early assessment? <<This patient is high risk & requires early assessment>>
If yes, please specify details: <<If yes (high risk) please provide details>>

Past genetic, medical, surgical, and obstetric history:
<<Clinical Details:History List>>
<<Clinical Details:Past Obstetric History>>

Current Medications: 
<<Clinical Details:Medication List>>

Allergies: 
<<Clinical Details:Allergies>>

Models of care
I have discussed models of care and this woman would like:
GP Shared Care: <<Models of 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: <<Clinical Details:Pap Smears>> 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 woman:  :<<Copy given to woman>>
2. OGTT for BMI > 35, previous GDM, macrosomic baby, PCOS:  <<OGGT for BMI>35,prev GDM,macro baby,PCOS>>
3. OGTT, E/LFT, Protein/Creatinine Ratio for women with BMI > 35: <<OGTT, E/LFT, Protein/Cr Ratio if 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 and Antibody ordered>>
11. Hepatitis B Serology:  <<Hepatitis B serology ordered>>
12. Hepatitis C Serology: <<Hepatitis C Serology>>

Thank you for your advice and management.

Yours sincerely,

	
<<Doctor:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>  Fax: <<Practice:Fax>>
Provider No.: <<Doctor:Provider Number>>
Email: <<Doctor:E-mail>>
<<Miscellaneous:Date (short)>>

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 YWC
                                                     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: 
<<Summary:Investigation Results (Selected)>>