GEPAS REFERRAL  -  RPA WOMEN & BABIES	   FAX: 9515 3454

PATIENT DETAILS                                                                  DATE: <TodaysDate>
Name: <PtName>	
Address: <PtAddress>	
Ph: <PtPhoneH>	Mobile: <PtPhoneMob>	
DoB: <PtDoB>	Age: <PtAge>	
Interpreter Required?     ¨ Yes       ¨ No	Language: 	

GP DETAILS 
Name: <DrName>	Provider #: <DrProviderNo>	
Address: <DrAddress>	
Ph: <DrPhone>	Fax: <DrFax>	

CLINICAL INFORMATION 				

LMP: <LMP>				
Serum BhCG:	

Please either fax relevant results to fax number given above or ask the patient to bring the results to the clinic appointment