MRN:	Date:	
	Surname:
<PtSurname>	Given Names:
<PtFirstName>	
Clinical Genetic Service	Address: <PtStreet>	
Dr Rani Sachdev & Dr Mary-Louise Freckmann		
Dominic Ross	<PtCity> , <PtState>, <PtPostcode>	
Level 1, Prichard Wing	Phone:	(H) <PtPhoneH>	(W)	
St George Hospital		(M) <PtPhoneMob>	
Telephone:	9113 3635	DOB: <PtDoB>	Ward/Hospital:	
Fax:		9113 3694			
Relevant History	Medicare:	exp:<PtMCExpiry>	
	<PtMCNo>	
Parity	G	P	M	T	Interpreter required	Y / N	
	Language:	
LMP		/	/	Reason for Referral	
		
Cycle length	days	£	Late Maternal Age		(>35 yrs at delivery)	
		
Ultrasound this pregnancy	Y / N	£	Family history of	
		
Date of ultrasound          /	/	_______________________________________________________________	
		
Gestation at ultrasound			£	Previous baby with congenital abnormality	
		
	weeks	days	_______________________________________________________________	
	£	Abnormal Ultrasound	(bring ultrasound report)	
Blood group:		
	_______________________________________________________________	
Allergies:		
	£	Consanguinity    (partner should also attend)		
		
Medications:	£	Possible Teratogen exposure    (notify us of details)	
		
	£	Other (eg. recurrent miscarriage >3)	
		
Provider No: <DrProviderNo>		
Print name:<DrName>	Comment:	
Address: <DrStreet>		
<DrCity> <DrState> <DrPostcode>		
Phone: <DrPhone>		
Fax: <DrFax>		
Signature:		
	Copy of report to:	
Date: <Date>