Gynaecology Referral Form 
The Royal Women's Hospital
Fax referral to: 8345 3036		
Do not fax if considering TOP – please provide referral to patient and ask her to Phone 1800 My Options on P: 1800 696 784
Dear Dr
As the Women's hospital health services operate mixed outpatient clients, we request all referrals to be addressed to a named medical practitioner. This enables us to provide patients with the choice of being treated as either a private or public patient.
Patient Details
First Name:<PtFirstName>	Last Name: <PtSurname>	Previous RWH patient: 	<Previous RWH patient>	
Date of birth: <PtDoB>	Medicare Number: <PtMCNo>/<PtMCLine>	Exp. date: <PtMCExpiry>	
Address: <PtAddress>	Health insurance fund: 	<PtHealthIns>
Health insurance number:	<Health Insurance Number>	
Home phone:<PtPhoneH>	Mobile:<PtPhoneMob>	ATSI? <Aboriginal - Torres SI>	
Interpreter required? <Interpreter required>
Language: <Language>	Disability or special needs? <Disabilities or special needs>	Specify: <Disabilities or special needs - Details>	
Country of birth: 	<PtCountry of Birth>		

Referring Doctor
Name: <DrName>	Provider number:	<DrProviderNo>	
Date of birth: <PtDoB>		
Address: <UsrAddress>	Phone: 	<UsrPhone>
Fax: 	<UsrFax>	

Reason for Referral / Diagnosis Please provide significant symptoms, signs, investigation results and any reason that identify a need for early hospital assessment. If there is insufficient information, triaging will be delayed. 
<Reason for Referral / Diagnosis>

BMI: <BMI>

Relevant Co-morbidities / Past Medical / Psychiatric / Genetic / Family History
<SelectedPMH>

Other relevant infromation: 
<Other relevant information>

Medicines:
<SelectedRx>

Allergies: 
<Reactions>

Rouine tests: 

FBE	o	Tumour Markers	o	
Ferritin	o	Hormonal Studies	o	
TFTs	o	Coagulation profile	o	
MSU	o	Pap smear	o	
Swabs	o	Pelvic Ultrasound	o	
		Mamogram	o	
Other: ___________________________

Pathology Provider: <Pathology provider> 	Radiology Provider: <Radiology provider>

Investigations: Attach relevant
<Ix>
Signature: 		  Date: <TodaysDate>

Appointment details will be sent to referring GP and patient. 
Referrals are triaged by a clinician based on the patient's residential address proximity to the Women's Hospital and the anticipated need for tertiary level care.
Guidance in assessing, managing and referring some problems can be found at https://melbourne.healthpathways.org.au
Please encourage your patient to link to their My Health Record (https://myhealthrecord.gov.au) via a phone app as its capability to upload pathology & imaging reports is increasing