GP ANTENATAL REFERRAL LETTER	
Dear ☐Dr Al Mashet, ☐Dr Glenn Blanchett, ☐Dr Sara Pixton ☐Dr Trupti Kanade (please tick one)
 thank you for seeing the following patient for antenatal care. 

Patient Name: <PtFullName>	DOB: <PtDoB>	
Medicare Number: <PtMCNo>	Address: <PtAddress>	
Interpreter required? <Interpreter required>
Language spoken at home: <Language spoken at home>

Current Pregnancy Details:
L.M.P: <LMP>
E.D.C: <EDC>
GRAVIDA: <GRAVIDA>
PRIMA: <PRIMA>
Current Pregnancy Concerns: <Current Pregnancy Concerns>
Significant Previous Obstetric History: <Significant Previous Obstetric History>
Previous Gynaecological History: <Previous Gynaecological History>

Medical History: 
<SelectedPMH>

Medications:
<CurrentRx>

Smoking: <SmkStatus>
Smoking History: <SmkHx>
Alcohol History: <AlcHx>

Allergies: 
<Reactions>

Immunisations: 
<Imm>

Examination:
Blood Pressure: <Blood Pressure>
Weight: <Weight>
Height: <Height>
Other Findings: <Other findings in examination:>

Antenatal Investigations Completed:
<Antenatal Investigations Completed>

Has NT or dating ultrasound been attended/booked? <Has NT or dating ultrasound been attended/booked?>

Comments: <Comments>

Referring Doctor Details: 
Name: <DrName>
Practice: <Practice>
Fax: <DrFax>
Phone: <DrPhone>
Provider Number: <DrProviderNo>
Signature: _________________________ 			Date: <TodaysDate>

I am accredited with the Nepean-Blue Mountains Antenatal Shared Care Program	<I'm accredited with Nepean-BM Antenatal Shared Care Prg>	

This patient is to return to me for GP Antenatal Shared Care	<This patient is to return to me for GP Antenatal Shared Care>	

PLEASE FAX COMPLETED FORM TO NEPEAN HOSPITAL ANC 4734 3213 AND GIVE HARD COPY TO PATIENT

PLEASE ATTACH RELEVANT INVESTIGATIONS TO THIS REFERRAL