Western Region Maternity Care Referral Form				
Fax referral to:
Djerriwarrh Health Service (DjHS) (Bacchus Marsh & Melton Regional Hospital)	Fax: 9746 0668	
Western Health (WH) (Sunshine Hospital)	Fax: 8345 1691	
Werribee Mercy Hospital	Fax: 8754 3467	
Mercy Hospital for Women	Fax: 8458 4205	

This form constitutes a valid referral to Djerriwarrh Health Service (Bacchus Marsh & Melton Regional Hospital), Western Health (Sunshine Hospital), Werribee Mercy Hospital and Mercy Hospital for Women provided all requested details are complete.

Patient Details	Referring Doctor Details	
First Name:  Patient Demographics.First Name	Last Name:  Patient Demographics.Surname	Name:  Treating Doctor.Name	
Previous last name: 		Practice Name:  Practice.Name	
Date of birth:  Patient Demographics.DOB		Practice address:Practice.Address	
Address:  	Patient Demographics.Full Address	 	

	Ph:  Practice.Phone	
		Fax:  Practice.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: Patient Demographics.Medicare Expiry Date	
ATSI status mother: 
	 Yes No  	ATSI status mother: 	 Yes No	Interpreter required:	  Yes No 
	Specify language:  
	Country of birth: 	Year of arrival if known:		
	
Previous Mercy patient: 
	 Yes No	Previous WH patient:    	 Yes No	Previous DjHS patient:	 Yes No	

Shared Care
I am able to provide shared care to the patient:	 Yes No 	Comment:  

Current Obstetric History	
LNMP:			Estimated delivery date: 		
Gravida:		Parity:		Known multiple pregnancy:	 Yes No	
Height:	  cm	Weight:	 kg	BMI*:		*must be included to enable triage and booking	
Last PAP test: date & result	Clinical Details.Pap Smear No Comments	Female circumcision:	Yes  No	
Clinical Details.Pap Smear With Comments

Past Obstetric History Check if applicable x  	
¨  Previous severe pre-eclampsia 	¨  Previous small baby <2800g	¨  Previous fetal abnormality (specify)	
¨  Mid trimester loss OR miscarriage x 3 or more	¨  Previous preterm birth <35 weeks ( specify gestation____)	¨  Previous Caesarean, how many_____	
¨  Still birth	¨  Placental abruption	¨  Gestational diabetes	
¨  Other (specify)	¨  Rhesus isoimmunisation	¨  PPH >= 1000mls	

Past Medical and Surgical History 

Clinical Details.History List

Social History 
Clinical Details.Social History
Risk Factors Relevant to Pregnancy Check if applicable x  	
¨  Diabetes pre pregnancy 	¨  Cervical surgery 	¨  Previous cone biopsy /2 or more LLETZ procedures	
¨  Heart disease 	¨  Anaemia	¨  Epilepsy 	
¨  Asthma requiring admissions or oral steroids within past 12 months 	¨  DVT or pulmonary embolus	¨  Thalassemia / haemoglobinopathy	
¨  Psychiatric disorders	¨  Hepatitis B or C	¨  High blood pressure/or on medication	
¨  Renal disease	¨  SLE	¨  Thyroid disease	
¨  Alcohol and other drugs (specify)		¨  Smoking	
¨  Family history of genetic disease (specify)		

Investigations /Test Results Provide results to your patient to bring to her first appointment 
	
Pathology Provider: 	
¨  FBE 	¨  HIV serology 		
¨  Blood group and antibodies	¨  MSU / urinalysis		
¨  Rubella 	¨  Ferritin		
¨  Hepatitis B  	¨  Syphilis serology		
¨  Hepatitis C  	¨  Thalassemia testing/ Hb electrophoresis		
¨  Consider GTT at 16 weeks: if past GDM, PCOs, BMI>35, Family history of diabetes, previous baby >4.5kg	
¨  Morphology 20 week Ultrasound (please provide details of ultrasound provider)
Please note for Werribee Mercy and Sunshine Hospital low-risk women will need to see their GP to order 20 week morphology scan, as these are not routinely available at the hospital.  Early requests may be accommodated for Mercy Hospital for Women with GPs being advised of outcome depending on capacity.
	
Consider:			
¨  Dating ultrasound	¨  Vitamin D	¨  Clamydia	
¨  GTT at 16 weeks: if past GDM, PCOS, BMI>35, Family history of diabetes, previous baby >4.5kg	

Aneuploidy Screening
Aneuploidy screening options have been discussed with the patient:        ¨  Yes       ¨  No
If yes: 
¨  First Trimester Combined Screen              (please provide details of ultrasound provider)
¨  Second Trimester MSST
¨  Non-invasive Prenatal screening using cell free DNA (please provide details of provider)
The patient has declined aneuploidy screening          ¨  Yes       ¨  No

Attach Relevant Investigations
Clinical Details.Result List (Selected)

Medications (please note if taken first trimester folate and iodine)
Clinical Details.Medication List

Allergies
Clinical Details.Allergies

Other Relevant Information 	
	
Doctor’s signature:		Date:	Miscellaneous.Date	

Appointment details will be sent to referring GP and patient.
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