The Royal Women’s Hospital
From practice software, email (preferred): referrals@thewomens.org.au
Fax referral to: (03) 8345 3036
Date: <TodaysDate>
Patient Details <Patient Details>
First Name:<PtFirstName>	Last Name: <PtSurname>	
Date of Birth: <PtDoB>              Gender: <GenderIdentity>	Medicare Number:  
<PtMCNo>/<PtMCLine>	Exp. Date: <PtMCExpiry>	
Address: <PtAddress>	
Home Phone: <PtPhoneH>	Mobile: <PtPhoneMob>	Email: <PtEmail>	
Language:  <Language>	Interpreter required? <Interpreter required>           	
Aboriginal or Torres Strait Islander? <Aboriginal or Torres Strait Islander?>	Disability or special needs?  <Disability or special needs>  
Details: <Disability or special needs - provide details>       	

Referring Doctor Details
First Name: <DrFirstName>	Last name: <DrSurname>	
Practice Name: <Practice>	Provider Number: <DrProviderNo>	
Practice Address: <UsrAddress>	
Phone: <DrPhone>	Fax: <DrFax>	Email: <DrEmail>	
Usual GP details (if not referring doctor): <Usual GP details (if not referring doctor)>	

Is this a re-referral in the same pregnancy (eg.change in patient condition or tests/information requiring review?) <Re-referral in the same pregnancy?>
Would this patient like to participate in Shared Maternity Care (if eligible)? <Interest in Shared Maternity Care?> 

Triaging questions <Triaging Questions>
Does this patient have a condition that may result in higher-risk pregnancy? <Higher risk pregnancy?>     
Does this patient	require early hospital assessment before 16 weeks gestation? <Early hospital assessment required?>
Fetal abnormality - known/concerns? <Concerns of fetal abnormality?>     
Is this referral for both maternity and clinical genetics? <Referral for both maternity and clinical genetics?>        
Provide details on any of the above: <Provide details on any of the above>
	
Current obstetric history <Current obstetric history>
Estimated delivery date: <EDD>   	LNMP: <LNMP>	Known multiple pregnancy: <Is this a known multiple pregnancy?>	
Gravidity: <Gravidity>	Parity: <Parity>	BP: <BP>	
Height (cm): <Height (cm)>	Weight (kg): <Weight (kg)>	BMI: <BMI>              	

Preventative care <Preventative care>
Tick if the patient has had the following:
<Folate and iodine supplementation>	Folate and iodine supplementation	
<Influenza vaccine this pregnancy>	Influenza vaccine this pregnancy	
<COVID immunised primary course>	COVID immunised primary course	
<Aspirin started due to risk factors>	Aspirin started due to risk factors
Commence aspirin 150 mg nocte orally from 12 weeks if previous pre-eclampsia or risk factors for pre-eclampsia. Do not wait for hospital review. See RACGP Guideline	

Past Obstetric History 
<Past obstetric history>

<Previous stillbirth>	Previous stillbirth		<Gestational Diabetes>	Gestational Diabetes	
<Previous fetal abnormality>	Previous fetal abnormality (specify)	<Previous pre-eclampsia/HELLP>	Previous pre-eclampsia/HELLP	
<Mid trimester loss OR miscarriage x3 or more>	Mid trimester loss OR miscarriage x2 or more	<Obstetric Cholestasis>	Obstetric Cholestasis		
<Preterm birth <37/40>	Preterm birth <37/40 (gestation:_______)	<Maternal red cell antibodies>	Maternal red cell antibodies	
<Fetal Growth Restriction or < 2800g at term>	Fetal Growth Restriction or <2800g at term 	<PPH >1000ml>	PPH >1000mls		
<Large baby >4500g at term>	Large baby >4500g at term	<Perinatal psychosis>	Perinatal psychosis	
<Cervical cerclage>	Cervical cerclage		<Previous caesarean/s>	Previous caesarean/s	
<Placental abnormalities/abruption>	Placental abnormalities/abruption	<Previous Neonatal Alloimmune Thrombocytopenia>	Previous Neonatal Alloimmune Thrombocytopenia	

Other obstetric condition/ additional details: 
<Other past obstetric condition/ additional details:>
Risk factors relevant to pregnancy
<Risk factors relevant to pregnancy>

<Medicine of concern>	Medicine of concern	<Diabetes pre-pregnancy>	Diabetes pre-pregnancy		
<Smoked in last 12 months>	Smoked in last 12 months	<Other endocrine disorder>	Other endocrine disorder	
<Current alcohol or illicit drug use>	Current alcohol or illicit drug use 	<Thalassaemia	>	Thalassaemia		
<Psychiatric disorders>	Psychiatric disorders	<Haematological/Coagulation disorder>	Haematological/Coagulation disorder	
<Family history of genetic disease/anomalies>	Family history of genetic disease/anomalies	<Hep B carrier or Hep C>	Hep B carrier or Hep C	
<Heart disease	>	Heart disease		<Infectious disease e.g. HIV>	Infectious disease e.g. HIV	
<Hypertension>	Hypertension 	<Current malignancy>	Current malignancy	
<Respiratory disease (including severe asthma)>	Respiratory disease (including severe asthma)	<Previous chemotherapy>	Previous chemotherapy	
<Gastrointestinal/Liver disease>	Gastrointestinal/Liver disease	<Uterine anomalies/fibroids>	Uterine anomalies/fibroids	
<Renal disease>	Renal disease		<Uterine/cervical surgery e.g. cone biopsy/LLETZ>	Uterine/cervical surgery e.g. cone biopsy/LLETZ	
<Neurological disease e.g. epilepsy>	Neurological disease e.g. epilepsy	<Female Genital Mutilation / Traditional Cutting>	Female Genital Mutilation / Traditional Cutting	
<Rheumatologic disease e.g. SLE>	Rheumatologic disease e.g. SLE		Other risk factor/ additional details: 
<Other risk factor/ additional details:>	

Patient history – additional details
Relevant medical and surgical history: 
<SelectedPMH>
	
Relevant mental health / social / genetic / family history:
<Relevant mental health / social / genetic / family history>
<SocialHx>
<FamilyHx>
	
Current medicines and supplements: 
<SelectedRx>
	
Allergies and reactions:
<Reactions>
	
Other relevant information / cultural safety/ alerts / family violence: 
<Other relevant information / cultural safety/ alerts / family violence>	

Investigations
•	Please attach results if available, or send via fax: (03) 8345 3036 or email: referrals@thewomens.org.au when available
•	If you are ordering tests for a patient (or potential patient) of the Women’s, add “RWH” in the cc box on your pathology request. This may enable transfer of results directly to the electronic medical record.  
Pathology Provider: <Pathology Provider>      Radiology Provider: <Radiology Provider>

Routine tests (tick all attached)
<FBE - attached>	FBE	
<Blood group and antibodies - attached>	Blood group and antibodies	
<Ferritin - attached>	Ferritin	
<Rubella antibodies - attached>	Rubella antibodies	
<Hepatitis B SAg - attached>	Hepatitis B SAg	
<Hepatitis C - attached>	Hepatitis C	
<HIV serology - attached>	HIV serology	
<Syphilis serology - attached>	Syphilis serology	
<MSU / urinalysis - attached>	MSU / urinalysis	
<12 week ultrasound (for nuchal translucency, dating and fetal number) - attached>	12 week ultrasound (for nuchal translucency, dating and fetal number)	
<Morphology ultrasound (20-22 weeks) - attached>	Morphology ultrasound (20-22 weeks)   
Please note: Not routinely available at the hospital and most women will need to have these ordered and followed-up by their GP	

Optional tests - to consider if clinically indicated 
Tests attached with referral: <Optional tests to consider if clinically indicated (select all results attached)>

Reproductive carrier screening (RCS) - once a lifetime         
Offer to all women in early pregnancy who have not previously had one 
Has the patient had RCS? (Please send results when available) <Reproductive carrier screening (RCS) done? (Once a lifetime)>

Aneuploidy testing 
Aneuploidy screening should be discussed and offered to all women irrespective of age. If high risk aneuploidy screening result, follow-up depending on test and result (eg. refer to Clinical Genetics service, NIPT/ CVS/ Amniocentesis)

Has the patient decided to have aneuploidy screening?  <Patient has decided to have aneuploidy screening?>
If completed, please attach: <Aneuploidy screening result attached>
If ordered, which test and provider (please cc RWH and forward result): <Aneuploidy screening test ordered>

Consent statement
•	I have obtained the patient’s consent for this referral, its mode of transmission, and to share sensitive, personal and health information 
•	I understand that following triage assessment, this referral may be redirected to a more suitable public health service. (If your patient does not consent to this, please indicate here: _________ )

Doctor’s signature:			                                                            Date: <TodaysDate>	

General information
•	If emailing referrals@thewomens.org.au and referral is urgent, use subject line: URGENT_Pt. Surname_DoB
•	Referrals are triaged based on the patient’s residential address proximity to the Women’s and the anticipated need for tertiary level care
•	If you do not receive a letter in 2 weeks that your referral has been accepted/declined, please contact the Access Centre: (03) 8345 2058, option 2
•	Appointment details will be sent to the patient
•	It is the referrer’s responsibility to continue to monitor the patient’s condition and notify us if there is a change that could affect the urgency of treatment, or the care required
•	Encourage your patient to use My Health Record to improve access to pathology/imaging reports and discharge summaries

Useful webpages
• Maternity Referrals: https://www.thewomens.org.au/health-professionals/for-gps/referrals/maternity-referrals 
• Clinical Genetics Referrals: https://www.thewomens.org.au/health-professionals/womens-health-services/sexual-reproductive-health/reproductive-services-main/clinical-genetics-service
• Maternity services overview and models of care: https://www.thewomens.org.au/health-professionals/maternity/maternity-overview 
• How we triage referrals: https://www.thewomens.org.au/health-professionals/for-gps/referrals/how-referrals-are-processed
• Sign up for Parkville Connect to access your patient’s electronic medical record: https://www.thewomens.org.au/health-professionals/for-gps/parkville-connect	

Insert investigations: <Ix>