Reproductive Services Referral Form
The Royal Women’s Hospital
Locked Bag 300, Level 2, Cnr Grattan & Flemington Rds, Parkville 3052
Phone: 03 8345 3200

Fax referral to: 03 8345 3036

Att.– Reproductive Services 
Date of referral       /       /      

Patient details
First Name      	Last Name      	Previous patient of the Women’s? ☐ Yes      ☐ No      		
Date of Birth      	☐ Female     ☐ Male  
☐ Non-binary   
☐ Prefer not to disclose 	Medicare Number      
Healthcare card:      	Exp. Date      	
Address      	Suburb      	Postcode      	
Home Phone      	Mobile      	Email      	
Aboriginal or Torres Strait Islander?

☐ Yes      ☐ No	Interpreter required?

☐ Yes      ☐ No      	 Language      	Country of birth      	
BMI?	☐ <35    ☐ >35	Disability/special needs?
☐ Yes (specify in next box)  ☐ No      	Specify: 
     	
Referring/treating doctor/hospital
Referring/treating Doctor      

Provider number:      	Referring hospital /Clinic:
     	
Phone      	Fax      	Email      	
Hospital Address      	Suburb      	Postcode      	
Diagnosis 
     

Length of time trying to conceive

     

Relevant past history including Gynaelogical and obstetric history

     

Is your patient seeking donor egg or donor sperm services? (Please circle Y / N )

Test and investigation results 
Please find below a list of the tests and investigations you need to provide in your referral. 
IMPORTANT: Results of these tests and investigations must be attached to the referral. 

      Primary patient investigations
☐ Hepatitis B & C	☐ HIV	
☐ Cervical screening test (CST)	☐ Rubella	
☐ Varicella	☐ Syphilis	
☐ FBE	☐ Blood group and antibodies	
☐ FSH	☐ LH	
☐ Prolactin	☐ Ferritin	
☐ Progesterone (day 21 for regular cycles and adjusted for irregular cycles)	☐ TSH	
☐ Estradiol (E2)	☐ Free testosterone	
☐ Sex Hormone Building Globulin (SHBG)	☐ Chlamydia/Gonorrhoea urine or endocervical PCR (if appropriate)	
☐ Anti Mullerian Hormone (optional)	☐ Pelvic ultrasound (trans-vaginal if possible)	
☐ Karyotype 
(Please note: if the patient declines this test, please still send through a referral. Please make a note here to advise the patient has declined this test).	

Pathology Provider      	Radiology Provider      	

Doctor’s signature
	Date	

Partner details (If applicable)
First Name      	Last Name      	Previous patient of the Women’s?
☐ Yes      ☐ No      	 	   	
Date of Birth      	☐ Female     ☐ Male
☐ Non-binary   
☐ Prefer not to disclose      	Medicare Number      
Healthcare card 	Exp. Date      	
Address      	Suburb      	Postcode      	
      	     	
Home Phone      	Mobile      	Email      	
Aboriginal or Torres Strait Islander?
☐ Yes      ☐ No	Interpreter required?

☐ Yes      ☐ No      	Language      	Country of birth      	
BMI?	☐ <35    ☐ >35	Disability/special needs?
☐ Yes (specify in next box) ☐ No      	Specify: 	

Relevant past history including Gynaelogical and obstetric history

Partner tests (if patient is accessing our service with a partner). 
Please find below a list of the tests and investigations you need to provide in your referral. 
IMPORTANT: Results of these tests and investigations must be attached to the referral. 

☐ Hepatitis B & C	☐ HIV	
☐ Karyotype 
(Please note: if the partner declines this test, please still send through a referral. Please make a note here to advise the partner has declined this test).	☐ Male hormones (if appropriate)	
☐ Semen analysis (if sperm provider)	☐ Semen antibodies (if appropriate)	

Pathology Provider      	Radiology Provider      	

Doctor’s signature
	Date