Canterbury Hospital
Endocrine/Maternity Clinic 
Referral Form

ANC Phone:   9787 0183
ANC Fax:        9787 0431 
Date of referral  <<Miscellaneous:Date>>	Surname: <<Patient Demographics:Surname>> Given Name: <<Patient Demographics:First Name>> 
DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Address>> , <<Patient Demographics:City>>, <<Patient Demographics:Postcode>>
Best contact Phone No: <<Best Contact Phone No.>>  
Mobile: <<Patient Demographics:Phone (Mobile)>>	
Is an interpreter required?  	    <<Is Interpreter Required?>>   If yes, which language: <<Language (if interpreter required)>>
Is the patient ineligible for Medicare? <<Is the patient ineligible for Medicare?>>  Has the patient already attended her booking visit at Canterbury Antenatal Clinic? <<Has the Patient Attended her Booking Visitl?>>  	
Clinical Information:   Gravida  <<Clinical Details:Gravida>> Para <<Clinical Details:Parity>> EDD <<Clinical Details:EDC>> Height:..............Weight...............                                                                                                                      
 Reason for referral:  ( tick all that apply) 
 0  Type I Diabetes  Mellitus  (RPA ONLY – ph 9515 5888)	 0   Hypothyroidism 
 0  Type 2 Diabetes Mellitus  					 0   Hyperthyroidism	
 0  Gestational Diabetes Mellitus (GDM) 			 	 0   Graves’ Disease	
 0  Impaired Fasting Glucose /Impaired Glucose Tolerance (IFG/IGT)    0   Thyroid nodule 	
		    						 0   Other endocrine disorder	
Investigations:  Date of results ……../………/……
Results sent with referral:   0 Yes   0 No, specify reasons……………………..	
NB: 75gms GTT results must include: 
•	0hr ( fasting) 
•	1 hr 
•	2 hrs 
•	+/- HbA1C (this will be attended at the GDM Group Education session)	NB: Thyroid Function Test results are current i.e < 3 weeks and must include :   
•	TSH               TgAb 
•	fT4                 TSH receptor Ab   
•	fT3                 25-OH-D3 
•	TPOAb 	
Current medications:   0  No 	0 Yes (please list)  
Other investigations performed :  0 Ultrasound   0 Other …………………………………………....…
Any other relevant clinical information ( eg. medical or pregnancy history) 	
Referrer Details: 
Referring Doctor: <<Doctor:Name>> 
Signature……………………………………………
Phone: <<Doctor:Phone>>
Provider Number: <<Doctor:Provider Number>>	

Canterbury Hospital Referrals: 
Please fax completed referral form and any relevant investigation reports to: (FAX)  9787 0431	
OFFICE USE ONLY
Date received ….…./……../……… Triaged by: ……………………………………………….
Clinic appt booked :  0 GDM Gp Education Date........./......../......... Time: 08.30 am (unbooked) or 8:50am (booked) 0 GDM Clinic   Date........./......../......... Time band:  09.00 – 11.30am  or 1pm – 3pm 
0 Thyroid Clinic  Date........./......../......... Time: ……………… Interpreter booked:   0 Yes 0 N/A   
0 Midwifwery Booking Appt   Date........./......../......... Time: …………… Data entered on  0 eMR
Patient notified by:	0 Phone  	0 Mail    Notified and processed by: 
Comments 	

Investigations:
<<Summary:Investigation Results (Selected)>>

Medication List:
<<Clinical Details:Medication List>>

Significant Medical History:
<<Clinical Details:History List>>