Women’s Health Specialist Clinics Referral Form

The Royal Women’s Hospital
From practice software, email (preferred): referrals@thewomens.org.au 
Fax referral to: (03) 8345 3036
Abortion and Contraception Service fax: (03) 8345 2833 or email: referrals@thewomens.org.au 
For eligibility criteria:  https://www.thewomens.org.au/health-professionals/abortion-contraception-service
If the patient does not meet the eligibility criteria, please direct them to 1800 My Options
<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?>  
 <Disability or special needs - provide details>	
Referring Doctor 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):>	
Referral Details <Referral Details>
Urgency: <Urgency>     	
Re-referral: Is this a re-referral for the same issue due to change in patient condition?   <Is this a re-referral for the same issue due to change in patient condition?>   	
Reason for Referral / Diagnosis: 
Please provide significant symptoms, signs, physical examination findings, diagnosis/provisional diagnosis (if known), investigations, management/treatment to date and any reasons that identify a need for urgent assessment. If there is insufficient information, triaging will be delayed.
<Reason for Referral / Diagnosis: --- Please provide significant symptoms, signs, physical examination findings, diagnosis/provisional diagnosis (if known), investigations, management/treatment to date and any reasons that identify a need for urgent assessment. If there is insufficient information, triaging will be delayed.---->

Patient history <Patient History>
Height (cm): <Height (cm)>
	Weight (kg): <Weight (kg)>
	BMI: <BMI>	
Relevant medical and surgical history:
<SelectedPMH>
	
Relevant mental health / social / genetic / family history:
<Relevant mental health / social / genetic / family history>
	
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 <Investigations>
• Please attach all relevant investigation results (<6 months old) to assist us to triage correctly. 
• Investigations required: https://www.thewomens.org.au/health-professionals/for-gps/referrals/womens-health-and-gynaecology-referrals
Attached test results:
<Tests attached with referral>
Radiology provider:			                                    Pathology provider:                 

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
• If you do not receive a letter in 2 weeks that your referral has been accepted/declined, please contact the Access Centre (GP use only): (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
• Women’s Health Specialist Clinics and referral criteria: https://www.thewomens.org.au/health-professionals/for-gps/referrals/womens-health-and-gynaecology-referrals 
• Referring to the Women’s including tips when sending and how we triage: https://www.thewomens.org.au/health-professionals/for-gps/referrals 
• Guidance on assessing, managing and referring some problems can be found on:
Health Pathways: https://melbourne.healthpathways.org.au 
Victoria’s Statewide Referral Criteria: https://www.health.vic.gov.au/statewide-referral-criteria
• 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 investigation results:
<Ix>