REQUEST FOR GYNAE CHOICES APPOINTMENT (SURGICAL TERMINATION OF PREGNANCY)		FAX ONLY to 03 4215 0806 (No ReferralNet)

GP Referral
		Referral Date: <TodaysDate>
Feedback Requested:  Yes	

Referral to:
Barwon Health Choices Clinic 
STOP only up to 14/40 

Refer via Barwon Health Social Work
Phone: 03 4215 0777
Fax:  03 4215 0806

Referral Urgency: <Referral Urgency>
Referral valid for: <Referral valid for>
		Referring General Practitioner:
Name:<DrName> 
Practice: <Practice> 
Address:<UsrAddress>
Phone: <UsrPhone>   
Fax:  <UsrFax>
Email: <DrEmail>
Provider No.: <DrProviderNo>	

Patient/Client/Consumer details:
Title: <PtTitle>
First name: <PtFirstName> 
Surname: <PtSurname>
Preferred Name: <PtPrefName>
Date of Birth: <PtDoB>   Age: <PtAge>
Sex at Birth: <PtSex>
Gender Identity: <GenderIdentity>
ATSI: <PtEthnicity>

Interpreter required: <Does the patient require an interpreter?>
Preferred language is: <If interpreter needed, which language>
Please consider Telehealth for this patient:
<Please consider Telehealth for this patient:>
Cultural safety requirements: <Cultural safety requirements?>
Access/Support requirements: <Access/Support requirements?>		Address: <PtAddress>
Mobile: <PtPhoneMob>
Email: <PtEmail>
Home Phone: <PtPhoneH>  
Work Phone: <PtPhoneWk>
Preferred method of communication: <Patient's preferred contact method>

Medicare: <PtMCNo> <PtMCLine> Expiry: <PtMCExpiry>
Pension/HCC: <PtPensionNo>
DVA: <PtDVANo>
Insurance: <PtInsFund> <PtInsNo>

NOK/Carer/Alternate contact:
Name: <NOKName>  Phone: <NOKContact>
Relationship: <NOKRelation>

	

Consent to referral: <Consent to referral>  
Consent to share information: <Consent to share information>
Is this a 2nd referral for the same problem: <Is this a 2nd referral for the same problem?>
Usual GP (if not referrer):  <Usual GP (if different to referrer)- Name/Practice>	

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
 			<HealthPathways Barwon guidance in Ax Mx referral>
Statewide Referral Criteria apply for Specialist Clinics Referrals. 
<Statewide Referral Criteria apply for Specialist Clinics Referrals.>	

Reason for referral:

<Reason for referral>

LNMP:  <LNMP if known>                 
Gestation Estimate: <Gestation estimate>
Blood Group & antibodies:   <Blood group & antibodies>              
BHCG:  <BHCG blood test request attached> 
Urine Chlamydia test attached:  <Urine Chlamydia test attached>
Urine Gonorrhea test attached:  <Urine Gonorrhea test attached> 
FBE:  <FBE  test attached> 
Bacterial vaginosis screen:  <Bacterial vaginosis test attached> 
Dating Ultrasound results attached:  <Dating Ultrasound results attached>	

Past Medical History:
<PMHActive>

Social History:
<SocialHx>

Family History:
<FamilyHx>

Current Medications:
<CurrentRx>

Alerts:
<Comment>

Allergies:
<Reactions>

Alcohol History:
<AlcHx>

Smoking Status:
<SmkStatus>
If smoker, smoking cessation discussed: <If smoker, smoking cessation discussed?>

Investigations/Results:
<Ix>

Electronically signed:  <DrName>