REFERRAL & ANTENATAL BOOKING FORM
St George / Sutherland Hospitals and Health Services
South Eastern Sydney Local Health District
Information about your health and wellbeing will be collected and be available to both the hospital and your GP unless otherwise requested.

Patient to complete this section	Phone ASAP for appointment or book online by 
searching for 'Sutherland antenatal appointment form'
or 'St George antenatal appointment form'	

Surname: <<Patient Demographics:Surname>>	Given Names:  <<Patient Demographics:First Name>>	
Previous/Maiden Name: 	Occupation: <<Patient Demographics:Occupation>>	
Marital status:    <<Patient Demographics:Marital Status>>	
Date of Birth:  <<Patient Demographics:DOB>>	Country of Birth:  	Religion:	
Language spoken at home:	Interpreter needed?      Yes o No o	
Will the baby be Aboriginal?      Yes o No o	Will the baby be Torres Strait Islander:        Yes o No o	
Pre-pregnancy weight:             Kg	Height:                  cm	
Home Address	Next of Kin	
Street:  <<Patient Demographics:Address Line 1>> 	Name:  <<Patient Demographics:Next of Kin>>	
<<Patient Demographics:Address Line 2>>	Relationship:  <<Patient Demographics:Next of Kin Relationship>>	
Suburb:  <<Patient Demographics:City>>	Street:  <<Patient Demographics:Next of Kin Address>>	
State:  <<Patient Demographics:State>> P/Code: <<Patient Demographics:Postcode>>	Suburb: 	
Phone no (H):  <<Patient Demographics:Phone (Home)>>	 State:  	
P/Code:  	

(w)  <<Patient Demographics:Phone (Work)>> (Mob)  <<Patient Demographics:Phone (Mobile)>>	Phone no: <<Patient Demographics:Next of Kin Phone>>	
E-mail address:  <<Patient Demographics:E-mail>>	
Medicare Eligibility:  Overseas (no medicare) o    Reciprocal o Medicare o	
 Medicare card no:  <<Patient Demographics:Medicare Number>>	 Exp date:  <<Patient Demographics:Medicare Expiry Date>>	
Health Fund:   Yes o No o	Fund name:  <<Patient Demographics:Health Insurance>>	Policy no: 	
Insured for pregnancy related services: Yes o No o Not sure o	
Are you aware of the obstetric private billing arrangement:   Yes o No o	

Have you previously attended St George Hospital before?	 Yes o No o	
Have you previously attended Sutherland Hospital before?	    Yes o No o	
If yes, under what surname?		

 Have you previously received pregnancy care at St George ( o ) or Sutherland (    o ) Hospitals? 
If so, which clinic did you attend?	

	

Would you like the same care for this pregnancy?	    Yes o No o	
(The options below is low risk pregnancy)	
Are you interested in the St George Birth Centre for your pregnancy care?	 Yes o No o	

To book your appointment, phone (02) 9113 2162 

or book online by searching for 'Sutherland 
antenatal appointment form' or 'St George 
antenatal appointment form' 

OTHER USEFUL PHONE NUMBERS
St George Hospital 
Main Switchboard			9113 1111
Sutherland Hospital
Main Switchboard			9540 7111
Interpreter Service			131 450	Please bring this completed form with you when you attend your first antenatal appointment. 

The location of your appointment will 
be advised on your appointment 
confirmation letter. 

REFERRAL & ANTENATAL BOOKING FORM
St George / Sutherland Hospitals and Health Services
South Eastern Sydney Local Health District

GP Name	
<<Doctor:Name>>	

Practice name	
<<Practice:Name>>	

Practice Address	
<<Practice:Address>>	

Fax:	
<<Practice:Fax>>	

Ph:	
<<Practice:Phone>>	

Provider no: 	
<<Doctor:Provider Number>>	

	THIS WOMAN IS SUITABLE AND INTERESTED IN SHARED CARE? 
   Yes o No o
GP Signature	

Date:	
<<Miscellaneous:Date (short)>>	

		
I wish to share my pregnancy care with my GP and the hospital clinic(s).  I understand that this involves sharing personal and health information between these two services.	
Name:	<<Patient Demographics:Full Name>>	Signature:		Date:	<<Miscellaneous:Date (short)>>	
	
Antenatal Clinic Consultants 	    SGH    
 o Dr T. Miller
	Drs G. Davis, M. Damasco, A.Henry 
	S. Kanitkar & K Kavanagh-Patel	   TSH     
 o Dr A. Zuschmann
	Drs J. Breen, D. Conrad, A. Harris &
	C. Krishnan	

NAME:	
<<Patient Demographics:First Name>>	

L.M.P	
<<Clinical Details:LNMP>>	
AGE	
<<Patient Demographics:Age>>	

E.D.C	
<<Clinical Details:EDC>>	

Gravida	
<<Clinical Details:Gravida>>	
Para	
<<Clinical Details:Parity>>	

PRESENT PREGNANCY   
  PV Bleeding:	
           Yes o No o	

Current Medications:	

	

Drugs of addiction:	

Cigarettes-no/daily:	
<<Clinical Details:Smoking>>	

Alcohol–gm/week:	
<<Clinical Details:Alcohol>>	

Allergies:	
<<Clinical Details:Allergies>>	

PREVIOUS OBSTETRIC HISTORY:

	

FAMILY HISTORY	
       Yes  No	

Congenital cardiac conditions	
      o      o	

Diabetes	
      o      o	

Hypertension	
      o      o	

Twins	
      o      o	

Hepatitis B	
      o      o	

 Other congenital abnormalities
(e.g. cleft palate, spina bidifa)	
 o      o	

Specify:	

v Interpreter needed?	
 Yes o No o	

v     Language required:	

EXAMINATION
BP	
	
at	
	
weeks gestation	

Heart	

BMI	

Lungs	
	
Thyroid	

Abdomen	

Breast examination	

Other findings	

	MEDICAL HISTORY 	
Yes	
No	

Cardiac	
o	
o	

Asthma	
o	
o	

Hypertension	
o	
o	

Diabetes	
o	
o	

Hepatitis	
o	
o	

Infertility	
o	
o	

Tuberculosis	
o	
o	

Sexually Transmitted Infections	
o	
o	

Transfusions	
o	
o	

Mental Illness	
o	
o	

Renal	
o	
o	

Epilepsy	
o	
o	

Other past History:	

	

SOCIAL HISTORY	

	

Please ensure the following results 
are available: 	

(and a copy to be sent to the Antenatal Clinic/Birth Centre) 	

Blood group & antibody screen 	
o	

Full blood count	
o	

Haemoglobin EPG (as per hosp. guidelines) 	
o	

Rubella IgG	
o	

Varicella IgG	
o	

Syphilis (ELISA)	
o	

Hepatitis B (surface antigen)	
o	

HIV/Hep C (offered with counselling)	
o	

Vitamin D	
o	

MSU for M/C/S	
o	

Chlamydia PCR if <25 or high risk	
o	

Early GTT required (as per protocol)	
o	

Date of last CST:	
<<Date of last CST>>	

18 weeks ultrasound booked 	
	
o	

Genetic counselling arranged 	
	
o	

NT Plus / NIPT	
	
o	

Early GTT required (as per protocol)	
	
o	

Is low dose aspirin required
(as per protocol)	
	
o	

Taking folate/iodine supplements	
	
o	

Updated December 2019