Referral Form - Maternal Fetal Medicine
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2Referral Form – Maternal Fetal Medicine
Women’s and Children’s Health Network
72 King William Road, North Adelaide SA 5006
Tel: 08 8161 9263
Fax: 08 8161 9264
Dr Chris Wilkinson
Prof Jodie Dodd
Assoc Prof John Svigos AM
Dr Peter Muller
Dr Rosalie Grivell
Dr Mark Morton
Dear __________________________________________________________________________________________
This referral has been discussed with (midwife/doctor) __________________________________________ at WCH
PATIENT DETAILS
Name: _________________________________________________________________________________________
Address: _______________________________________________________________________________________
Date of Birth: __________________________________
Phone: _______________________________________ Mobile: __________________________________________
Medicare Number: ______________________________ Medicare Expiry: __________________________________
Support person: ________________________________ Phone: __________________________________________
Interpreter required: No
Yes
Language: _______________________________________
ATSI Status: No
Yes, Aboriginal Yes, Torres Strait Islander
Yes, Aboriginal & Torres Strait Islander
Other considerations & patient requirements: __________________________________________________________
REFERRING PRACTITIONER DETAILS
Referring Doctor: ________________________________________________________________________________
Provider Number: _____________________________ Phone: _____________________________________________
Address: _______________________________________________________________________________________
Signature: ___________________________________ Date: ______________________________________________
CLINICAL INFORMATION
The following information must be provided with this referral request.
EDD
Current GA
Gravidity
Parity
Blood Group + Abs, blood tests
Previous obstetric history
Relevant medical/surgical history
Most recent ultrasound scan report
Date:
Location:
Declined
No
Yes. Result:
Maternal Serum Screening
Declined
No
Yes. Result:
Nuchal Translucency Scan
Additional clinical information
Last updated: 7 September 2015
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