GYNAECOLOGY OUTPATIENT CLINICS – THE SUTHERLAND HOSPITAL
Patients to bring Medicare card and Ultrasound report if they have one.
Please send GP Referral to either fax: (02) 9540 37304 
Gynaecology Clinic
□	Menorrhagia		□     Uterine Fibroid	□    PV Bleeding
□	Endometrial Polyp	□     Ovarian Cyst	□    Irregular Menstrual Periods
□	Cervical Polyp		□     Subfertility    	□    Infertility
□	Mixed gynaecological symptoms
□	Implanon and Mirena insert or removal 
Colposcopy Clinic
□	Abnormal cervical screening results that require colposcopy
□	Post coital bleeding
Menopause Clinic
□	Menopause problems
NB:	For uterine problems or stress incontinence problem refer to Pelvic Floor Bladder Unit on (02) 9113 2272

SUTHERLAND HOSPITAL
GYNAECOLOGY OUTPATIENT CLINICS	PATIENT REFERRAL FORM	

Outpatients Clinic Use Only	Referral to:	
Referral received: 		
Referral notified or receipt::		

Patient Details:

Title	Surname:	First Name: 	
<PtTitle>	<PtSurname>	<PtFirstName>	
Address: 	<PtStreet>	
Suburb: <PtCity>	Postcode: <PtPostcode>	
Medicare No: <PtMCNo>	DOB: <PtDoB>	
Sex/Gender: <PtSex>	
Compensable Status: 	DVA □  WorkCover □ Motor Vehicle  Third Party Insurance □ 	Other □	
Phone W (work): 	Phone H (home): 	Phone M (mobile): 	
<PtPhoneWk>	<PtPhoneH>	<PtPhoneMob>	
Email: <PtEmail>	Communication Preferrence:
Phone W □ Phone H □ Phone M □ Email □	
Identifies as Aboriginal or Torrest Strait Islander: 
YES □  NO □	Special Needs/reasonable adjustment required for disability:  YES □  NO □	
Interpreter Required:
 YES □  NO □
Language: 	Description: 
	
Carer Name: 	GP Name (if not the referrer): 	
Phone: 	Phone/email: 	
Email: 	Address: 	

Clinical Details:
REASON FOR REFERRAL:
(including presenting symtoms - onset, duration and severity if appropirate - physical findings):  

Any previous treatment or investigation of referral condition? 	YES □  NO □	
Description (please attach investigations outcomes)		
Any previous surgery?	YES □  NO □	
Description		
Any other coexisting conditions?	 YES □  NO □   	
Description		
Any current medications (including allergies)	YES □  NO □ 	

ALLERGIES:
<Reactions>

MEDICATIONS:
<SelectedRx>

Referrer Details:
Name: <DrName>	GP □  Other □ 	
Provider Number: <DrProviderNo>	Phone: <DrPhone>	
Email: <DrEmail>	Fax: <DrFax>	
Signature: 
	Date: <TodaysDate>	

Other Details If Required:

PATHOLOGY RESULTS:
<Ix>