Maternity Care Referral Form	
Provided this form is complete, it constitutes a valid referral to Djerriwarrh Health Service (Bacchus Marsh & Melton Regional Hospital), Werribee Mercy Hospital and Western Health (Sunshine Hospital).	
		
Djerriwarrh Health Service (Dr Nisha Khot – Head of Unit)	Fax: 9746 0668	
Werribee Mercy Hospital (Dr Jacqueline Van Dam (Head of Unit)	Fax: 8754 6710	
Western Health (Dr Elske Posma – Head of Unit)	Fax: 9055 2125	

Patient Details				Referring Doctor Details	
First Name: 	<<Patient Demographics:First Name>>	Last Name:	<<Patient Demographics:Surname>>	Name:  <<Doctor:Name>>	
Previous last name:	<<Previous last name>>			Practice Name: <<Practice:Name>>	
Date of birth:	<<Patient Demographics:DOB>>			Practice address: <<Doctor:Address>>	
Address:	<<Patient Demographics:Address>>			Suburb: <<Doctor:City>>	Postcode: <<Doctor:Postcode>>	
				Ph: <<Practice:Phone>>	
Suburb:	<<Patient Demographics:City>>	Postcode	<<Patient Demographics:Postcode>>	Fax:  <<Practice:Fax>>	
Home phone	<<Patient Demographics:Phone (Home)>>	Mobile	<<Patient Demographics:Phone (Mobile)>>	Provider number: <<Doctor:Provider Number>>	
Medicare no.:	<<Patient Demographics:Medicare Number>>			Date: <<Miscellaneous:Date (short)>>	
					
Interpreter required:	<<Interpreter Required>>	Specify language:	<<Interpreter: Specify language>>	Disabilities or special needs
<<Disabilities or special needs>>
<<Disabilities or special needs (detail)>>	

Shared Care
I/My practice is able to provide shared care to the patient:	¨ Yes	¨ No
Please nominate suggested shared care practitioner: ……........................................	Comment: 

Current Obstetric History
LNMP: 	<<Clinical Details:LNMP>>	Estimated delivery date: 	<<Estimated delivery date>>
Gravida: 	<<Clinical Details:Gravida>>	Parity: 	<<Clinical Details:Parity>>	Known multiple pregnancy: 	<<Known multiple pregnancy>>
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	

	

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:Medication List>>

Allergies
<<Clinical Details:Allergies>>

Other Relevant Information
<<Other Relevant Information>>

Doctor’s signature:		Date:	<<Miscellaneous:Date (short)>>	

Appointment details will be sent to referring GP and patient.
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