Maternity Referral Form
The Royal Women's Hospital
Fax referral to: 8345 3036		
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>	Exp. date: <PtMCExpiry>	
Address: <PtAddress>	Health insurance fund: 	<PtHealthIns>	
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: 	<Country of Birth>		

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

Would like to participate in shared care if eligible: 	o Yes
Need for tertiary obstetric care?	o Yes	o No	Provide Details:	
		
Need for hospital assessment before 16 weeks gestation?	o Yes	o No	Provide Details: 	
		
Aspirin started	o Yes
(Commence aspirin 150 mg nocte orally in the first trimester if previous preeclampsia. Do not wait for hospital review)
Current Obstetric History
LNMP: 	<LMP>		Estimated delivery date: <EDC>
Gravida: 	<Gravida>	Para: <Parity>	Known multiple pregnancy:  o Yes  o No
Height:	<Height (cm)>	cm	Weight:  	<Weight (kg)>	kg	Fetal abnormality (known/concerns)  o Yes  o No
BMI: 	<18.5,    18.5 - 35,    If > 35 (please indicate <BMI> )	BP: <BP - Systolic> / <BP - Diastolic>

Alcohol	o Yes	Iodine supplementation	o Yes	Flu vaccine this pregnancy	o Yes
Smoked in last 12 months	o Yes	1st trimester folate	o Yes	COVID immunised (both doses)	o Yes
Illicit drugs	o Yes

Past Medical and Surgical History
<PMHAll>

Past or present mental health issues
<Past or present mental health issues>

Social History
<SocialHx>

Past Obstetric History

o  Not applicable - primigravida	o  Not applicable - no relevant past obstetric 

Previous stillbirth 		o Yes	Gestational Diabetes	o Yes	
Previous fetal abnormality (specify)	o Yes	Previous severe pre-eclampsia/HELLP 	o Yes	
Mid trimester loss OR miscarriage x3 or more	o Yes	Obstetric Cholestasis	o Yes	
Preterm birth <37/40 (gestation) _______	o Yes	Maternal red cell antibodies	o Yes	
IUGR or <2800g at term	o Yes	PPH >1000mls	o Yes	
Large baby > 4500g at term	o Yes	Previous Neonatal Alloimmune Thrombocytopenia	o Yes	
Cervical cerclage	o Yes	Perinatal psychosis	o Yes	
Placental abnormalities/abruption	o Yes	Previous caesarean		
Other: 				

Risk factors relevant to pregnancy

o  Not applicable - no relevant risk factors

Alcohol and other drugs (specify)	o Yes	Diabetes pre-pregnancy	o Yes	
Psychiatric disorders	o Yes	Other endocrine disorder (specify)	o Yes	
Family history of genetic disease/anomalies (specify)	o Yes	Thalassaemia	o Yes	
Heart Disease	o Yes	Haematological/Coagulation disorder e.g. sickle cell	o Yes	
Hypertension	o Yes	Hep B carrier or Hep C	o Yes	
Respiratory Disease including severe asthma	o Yes	Infectious disease e.g. HIV	o Yes	
Gastrointestinal/liver Disease	o Yes	Current malignancy	o Yes	
Renal Disease	o Yes	Previous chemotherapy	o Yes	
Neurological Disease e.g. epilepsy	o Yes	Uterine anomalies/fibroids	o Yes	
Rheumatologic Disease e.g. SLE	o Yes	Uterine/cervical surgery e.g.   cone biopsy/LLETZ procedure	o Yes	

Other: 	

Investigations: Please attach results if available or fax on 03 8345 2623 when available
If you are ordering tests for a patient (or potential patient) of the Women’s, PLEASE add RWH in the cc box on your pathology request.  This will enable electronic transfer of results to the women’s electronic medical record.  If the patient has not previously attended the RWH (eg this is a new referral) please also attach pathology and ultrasound results to this referral prior to faxing

Pathology Provider:  <Pathology Provider>	Radiology Provider:  <Radiology Provider>
Routine tests

FBE	o	Rubella	o	Hepatitis C	o	
Blood group and antibodies	o	HIV serology	o	Syphilis serology	o	
Ferritin	o	Hepatitis B carrier	o	MSU / urinalysis	o	
12 week Ultrasound (Nuchal translucency, number and dating)	o	

Morphology Ultrasound (20-22 weeks)     o

Please note: Not routinely available at the hospital and most women will need to have these ordered by their GP 
	
Tests to consider	
Fasting glucose & HbA1c (if high risk of developing GDM)	o	Thalassemia test	o	Varicella Ab	o	
Early  ultrasound (eg at 8 weeks if dates uncertain or concerns regarding viability)	o	TSH	o	Chlamydia	o	

Aneuploidy testing  Aneuploidy testing should be discussed and offered to all women irrespective of age.
Patient has decided to have aneuploidy testing	o Yes               o No

If yes:
First Trimester Combined Screen
or	completed	o	ordered	o	Provider	
NIPT (high risk of aneuploidy or primary screen)
or	completed	o	ordered	o	Provider	
Second Trimester MSST	completed	o	ordered	o	Provider	
If high risk aneuploidy screening result consider CVS/Amniocentesis	completed	o	ordered	o	Provider	
Reason: 		

Medicines
<SelectedRx>

Allergies
<Reactions>

Other relevant information

Investigations: 
<Ix>

Doctor's 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 on the https://www.thewomens.org.au/wm-scguide and https://melbourne.healthpathways.org.au
Please encourage your patient to link to their https://myhealthrecord.gov.au/internet/mhr/publishing.nsf/Content/appconnect via a phone app as its capability to upload pathology & imaging reports is increasing