Canterbury Hospital
Endocrine/Maternity Clinic 
Referral Form

ANC Phone:   9787 0183
ANC Fax:        9787 0431 
Date of referral  <TodaysDate>	Surname: <PtSurname> Given Name: <PtFirstName> 
DOB: <PtDoB>
Address: <PtStreet> , <PtCity>, <PtPostcode>
Best contact Phone No: <Best Contact Phone No.>  
Mobile: <PtPhoneMob>	
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 Already Attended her Booking Visit?>  	
Clinical Information:   Gravida        Para <Parity> EDD <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: <DrName> 
Signature……………………………………………
Phone: <DrPhone>
Provider Number: <DrProviderNo>	

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:
<Ix>

Medication List:
<SelectedRx>

Significant Medical History:
<SelectedPMH>