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: <<Patient Demographics:Full Name>>	DOB: <<Patient Demographics:DOB>>	
Medicare Number:<<Patient Demographics:Medicare Number>>	Address:<<Patient Demographics:Address>>	
Interpreter required? <<Interpreter required?>>
Language spoken at home: <<Lanuage spoken at home>>

Current Pregnancy Details:
L.M.P: <<Clinical Details:LNMP>>
E.D.C: <<Clinical Details:EDC>>
GRAVIDA: <<Clinical Details:Gravida>>
PRIMA: <<PRIMA>>

Current Pregnancy Concerns: <<Current Pregnancy Concerns>>
Significant Previous Obstetric History: <<Clinical Details:Past Obstetric History>>
Previous Antenatal History: <<Clinical Details:Antenatal History>>
Previous Gynaecological History: <<Previous Gynaecological History>>

Medical History: 
<<Clinical Details:History List>>

Medications:
<<Clinical Details:Medication List>>

Smoking: <<Clinical Details:Smoking>>

Alcohol: <<Clinical Details:Alcohol>>

Allergies: 
<<Clinical Details:Allergies>>

Immunisations: 
<<Clinical Details:Immunisation List>>

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

Antenatal Investigations Completed:
<<Antenatal Investigations Completed>>

Comments: <<Comments>>

Referring Doctor Details: 
Name: <<Doctor:Name>>
Practice: <<Practice:Name>>
Fax: <<Practice:Fax>>
Phone: <<Practice:Phone>>
Provider Number: <<Doctor:Provider Number>>
Signature: _________________________ 		Date: <<Miscellaneous:Date (short)>>

I am accredited with the Nepean-Blue Mountains Antenatal Shared Care Program	<<Accredited with the NBM ANC Pgm?>>	

This patient is to return to me for GP Antenatal Shared Care	<<Patient must return to me for GP ANC?>>	

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

PLEASE ATTACH RELEVANT INVESTIGATIONS TO THIS REFERRAL