GYNAECOLOGY OUTPATIENT CLINICS – ST GEORGE HOSPITAL
Patients to bring Medicare card and Ultrasound report if they have one.
Please send GP Referral to either fax: (02) 9113 3765 or email to:
SESLHD-StGeorge-GynaeClinic@health.nsw.gov.au
Gynaecology Clinic
□	Menorrhagia		□     Uterine Fibroid	□    PV Bleeding
□	Endometrial Polyp	□     Ovarian Cyst	□    Irregular Menstrual Periods
□	Cervical Polyp		□     Subfertility    	□    Infertility
□	Mixed gynaecological symptoms
□	Implanon insert or removal 
Hysteroscopy Clinic
□	Endometrium Thickening
□	Mirena insertion (BYO) or removal
□	Multi-load IUD (Copper IUD) insertion
□	IUD removal 
Colposcopy Clinic
□	Abnormal cervical screening results that require colposcopy
□	Post coital bleeding
Menopause Clinic
□	Menopause problems
NB:       For uterine prolapse or stress incontinence problem refer to Pelvic Floor Bladder Unit on (02) 9113 2272
ST GEORGE HOSPITAL
WOMEN’S AND CHILDREN 
PATIENT REFERRAL TO GYNAECOLOGY
OUTPATIENT SERVICE
Level 1, Prichard Wing – St George Hospital
Gynaecology Tel: (02) 9113 2162 Fax: (02) 9113 3765
Email:  SESLHD-StGeorge-GynaeClinic@health.nsw.gov.au

Referral to: 	Professor Michael Chapman, Dr Trent Miller, Dr Gavin Sacks, Dr Chandra Krishnan, Dr Greg Davis, Dr John Breen, Dr Steven Thou, Dr David Rosen, Dr Monique Damasco, Dr Ludmilla Collins, Dr Queeny Wong, Dr Kate Kavanagh-Patel 

Patient Surname: <<Patient Demographics:Surname>>       First Name: <<Patient Demographics:First Name>>
DOB: <<Patient Demographics:DOB>>	
Address:   <<Patient Demographics:Full Address>>

Phone Number: <<Patient Demographics:Phone (Home)>>	Mobile: _<<Patient Demographics:Phone (Mobile)>>

  Medicare No: <<Patient Demographics:Medicare Number>>

Note: include patient’s reference number as the eleventh number of the Medicare card 
INTERPRETER REQUIRED: YES/NO		Dialect:  _________________________________________
REASON FOR REFERRAL:  

MEDICATIONS:
<<Clinical Details:Medication List>>

Results attached:	YES / NO

REFERRING DOCTOR’S SIGNATURE_____________________________	DATE <<Miscellaneous:Date (short)>>

Requesting DR:		
 Provider No:		
Telephone:		
Address:		

PATHOLOGY RESULTS:
<<Summary:Investigation Results (Selected)>>