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REQUEST FOR CONSULTATION GOLD COAST HOSPITAL AND HEALTH SERVICE ANTENATAL CLINIC Dr Anne Sneddon Dr Richard Loong Dr Vanitha Math Dr Donald Angstetra Dr Derryck Charters Dr Ramesh Vasant Dr Tina Fleming Dr Tania Widmer SEND TO: Dr Anne Sneddon (Director of Obstetrics and Gynaecology) Gold Coast University Hospital Antenatal Bookings Fax: 07 5687 1597 OR FROM: <<Doctor:Name>> <<Practice:Name>> <<Practice:Address>> Phone: <<Practice:Phone>> Fax: <<Practice:Fax>> Secure transmission service via Medical Objects, Healthlink or Argus to: Email: <<Doctor:E-mail>> QHEALTH, GOLD COAST HEALTH Antenatal Provider Number: <<Doctor:Provider Number>> Antenatal Bookings and Referrals Signature Please ensure the Patient meets the following critera: Patients should only be referred after 12 weeks gestation with a complete set of antenatal bloods and 12 week nuchal translucency scan (unless Patient declines the latter). <<Please ensure Patient meets the following criteria>> For urgent pregnancy related issues please phone: Maternity GP Liaison Mon-Fri 8am-4:30pm Phone: 5687 1525 Birth Suite at all other times <<For urgent pregnancy related issues please phone:>> Date: <<Miscellaneous:Date (short)>> Dear Dr Sneddon RE: <<Patient Demographics:Full Name>> Maiden Name (or any other Surname): <<Maiden Name (or any other Surname)>> DOB: <<Patient Demographics:DOB>> Gender: <<Patient Demographics:Sex>> Medicare Number*: <<Patient Demographics:Medicare Number>> *[Medicare ineligible patients will incur an appointment fee] Address: <<Patient Demographics:Full Address>> Home Ph: <<Patient Demographics:Phone (Home)>> Mobile Ph: <<Patient Demographics:Phone (Mobile)>> Alternative Contact Name: <<Alternative Contact Name>> Alt. Contact’s Phone: <<Alternative Contact Phone no>> [Alternative contact may be used to contact the patient if they cannot be reached via the contact details given] Interpreter Required : <<Interpreter Required >> Please specify Language: <<Please specify Language>> Reason for Referral: [Please ensure this information is supplied] Include as much relevant information as possible about your patient's condition to optimise their chances of being triaged correctly eg diagnosis, duration, severity and impact. Has the Patient been seen by a Consultant in this specialty in the GCHHS in the past? <<Has patient seen this GCHHS specialty in the past?>> If yes, provide GCHHS Consultant's name <<If yes, provide GCHHS Consultant's name>> Please indicate the type of care required for this patient. <<Type of care>> <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB>> Coast Medicare Local and Gold Coast Health Jan 2014 Developed in Partnership by General Practice Gold Coast, Gold If hospital outreach care is available which venue would suit you? <<Preferred location for outreach Antenatal care>> Obstetric History: Previous Preterm Labour: <<Previous Preterm Labour>> Gestation of Previous Preterm Labour: <<Gestation of Previous Preterm Labour>> Gravida: <<Clinical Details:Gravida>> Para: <<Clinical Details:Parity>> Miscarriage: <<Miscarriage? TOP: <<TOP? (number) >> (number)>> Ectopic: <<Ectopic pregnancy? (number)>> LMP: <<Clinical Details:LNMP>> EDC: <<Clinical Details:EDC>> Current gestation by dates: <<Current gestation by dates>> Current gestation by scan: <<Current gestation by scan>> Medical History: Smoking Status: <<Clinical Details:Smoking>> Blood Group:<<Blood Group>> BMI: <<BMI >> <<Clinical Details:History List>> Surgical History: <<Surgical History>> Psychological History: <<Psychological History>> Allergies: <<Clinical Details:Allergies>> Current Medications: <<Clinical Details:Medication List>> PLEASE ENSURE APPROPRIATE PRE-REQUISITE TESTS HAVE BEEN PERFORMED AND ARE ATTACHED. For ALL subsequent tests please cc Antenatal Clinic Gold Coast University Hospital. Tests to be performed on referral FBC Blood Group Antibody Screen Rubella Hepatitis B and C HIV and Syphilis Serology MSU <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB>> Coast Medicare Local and Gold Coast Health Jan 2014 Developed in Partnership by General Practice Gold Coast, Gold 12 week Nuchal Translucency Scan (unless patient declines) Results: <<Summary:Investigation Results (Selected)>> <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB>> Coast Medicare Local and Gold Coast Health Jan 2014 Developed in Partnership by General Practice Gold Coast, Gold
