GEPAS REFERRAL  -  RPA WOMEN & BABIES	   FAX: 9515 3454

PATIENT DETAILS                                                                  DATE: <<Miscellaneous:Date>>
Name: <<Patient Demographics:Full Name>>	
Address: <<Patient Demographics:Full Address>>	
Ph: <<Patient Demographics:Phone (Home)>>	Mobile: <<Patient Demographics:Phone (Mobile)>>	
DoB: <<Patient Demographics:DOB>>	Age: <<Patient Demographics:Age>>	
Interpreter Required?     ¨ Yes       ¨ No	Language: 	

GP DETAILS 
Name: <<Doctor:Name>>	Provider #: <<Doctor:Provider Number>>	
Address: <<Doctor:Full Address>>	
Ph: <<Doctor:Phone>>	Fax: <<Doctor:Fax>>	

CLINICAL INFORMATION 				

LMP: <<Clinical Details:LNMP>>				
Serum BhCG:	

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