REQUEST FOR GYNAE CHOICES APPOINTMENT (SURGICAL TERMINATION OF PREGNANCY)		FAX ONLY to 03 4215 0806 (No ReferralNet)
							
GP Referral
		Referral Date: <<Miscellaneous:Date (short)>>
Feedback Requested:  <<Feedback requested>>

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:<<Doctor:Name>>
Practice: <<Practice/Location:Name>>
Address:<<Practice/Location:Address>>
Phone: <<Practice/Location:Phone>>  
Fax:  <<Practice/Location:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>	

Patient/Client/Consumer details:
Title: <<Patient Demographics:Title>>
First name: <<Patient Demographics:First Name>>
Surname: <<Patient Demographics:Surname>>
Preferred Name: <<Patient Demographics:Known As>>
Date of Birth: <<Patient Demographics:DOB>>  Age: <<Patient Demographics:Age>>
Gender: <<Patient Demographics:Gender>>
ATSI: <<Patient Demographics:ATSI>>
Interpreter required: <<Patient Demographics:Requires Interpreter>>
Preferred language is: <<Patient Demographics:Language Spoken>>
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: <<Patient Demographics:Address>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Email: <<Patient Demographics:E-mail>>
Home Phone:  <<Patient Demographics:Phone (Home)>>
Work Phone: <<Patient Demographics:Phone (Work)>>
Preferred method of communication: <<Patient preferred contact method>>

Medicare: <<Patient Demographics:Medicare Number>> Expiry: <<Patient Demographics:Medicare Expiry Date>>
Pension/HCC: <<Patient Demographics:Pension Number>>
DVA: <<Patient Demographics:DVA Number>>
Insurance: <<Patient Demographics:Health Insurance>>

NOK/Carer/Alternate contact:
Name: <<Patient Demographics:Next of Kin>> 
Phone: <<Patient Demographics:Next of Kin Phone>>
Relationship: <<Patient Demographics:Next of Kin Relationship>>

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 Clinic>>	

Reason for referral:
<<Reason for referral>>

LNMP:  <<LNMP if known>>
Gestation Estimate: <<Gestation estimate>>
Blood Group and antibodies:  <<Blood Group & antibodies>>
BHCG result attached:  <<BHCG results attached>>
Urine Chlamydia result attached:  <<Urine chlamydia result attached>>
Urine Gonorrhoea result attached:  <<Urine gonorrhoea result attached>>
FBE result attached:  <<FBE result attached>>
Bacterial vaginosis screen attached:<<Bacterial vaginosis screen result attached>>
Dating ultrasound results attached:  <<Dating ultrasound results attached>>

Past Medical History:
<<Clinical Details:History List>>

Social History:
<<Clinical Details:Social History>>

Family History:
<<Clinical Details:Family History>>

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

Alerts:
<<Clinical Details:Warnings>>

Allergies:
<<Clinical Details:Allergies/Adverse Reactions>>

Alcohol History:
<<Clinical Details:Alcohol>>

Smoking Status: <<Clinical Details:Smoking>>
<<If smoker, smoking cessation discussed: >>

Investigations/Results:
<<Summary:Investigation Results (Selected)>>

Electronically signed: <<Doctor:Name>>