<Letterhead>
ROYAL PRINCE ALFRED HOSPTIAL MEDICAL GENOMICS
REFERRAL FORM
Clinical Geneticists	Genetic Counsellors
Dr Jason Pinner	Ron Fleischer
	Lucinda Freeman
	Zara Richmond
	Laura Molloy	

Date:
To: 	<TodaysDate>
Drs Jason Pinner 
Dept of Clinical Genetics
Royal Prince Alfred Hospital
	
Phone:	9515 5080	
Fax:	9515 5490	

Referring Doctor:

<DrName>

Provider No:<DrProviderNo>	
Phone:	<DrPhone>	
Fax:	<DrFax>	
Signature:		
Completed by:		

Patient Name: 	<PtName>	
DOB:	<PtDoB>	
Tel (Daytime):	<PtPhoneH>	
Mob:	<PtPhoneMob>	
Address:	<PtAddress>	
LMP/EDD:	<LMP> / <EDC>	
Interpreter required:
(specify language)	£ Yes	

Prenatal counselling	
£	Increased risk screening result.
Please include copies of all results	
£	Teratogen/medication exposure.
(Alternatively call Mothersafe – 9382 6539)	
£	Consanguinity.	
£

£	Family history of intellectual disability and/or congenital abnormality.
Family history of stillbirth or recurrent miscarriage	
£

£	Hereditary condition in the family (please specify)
Thalassaemia
All thalassaemia referrals must be accompanied by FBC, Haemoglobin EPG and Iron Studies results for both the patient and their partner	
£	Other (Please specify): 	
Clinical Details: 	

For urgent referrals please contact the Clinical Geneticist on call via the RPAH switchboard 9515 6111