MRN:	Date:	
	Surname:
<<Patient Demographics:Surname>>	Given Names:
<<Patient Demographics:First Name>>	
Clinical Genetic Service	Address: <<Patient Demographics:Address Line 1>>	
Dr Rani Sachdev & Dr Mary-Louise Freckmann	<<Patient Demographics:Address Line 2>>	
Dominic Ross	<<Patient Demographics:City>> , <<Patient Demographics:State>>, <<Patient Demographics:Postcode>>	
Level 1, Prichard Wing	Phone:	(H) <<Patient Demographics:Phone (Home)>>	(W)	
St George Hospital		(M) <<Patient Demographics:Phone (Mobile)>>	
Telephone:	9113 3635	DOB: <<Patient Demographics:DOB>>	Ward/Hospital:	
Fax:		9113 3694			
Relevant History	Medicare:	exp:<<Patient Demographics:Medicare Expiry Date>>	
	<<Patient Demographics:Medicare Number>>	
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: <<Doctor:Provider Number>>		
Print name:<<Doctor:Name>>	Comment:	
Address: <<Doctor:Address Line 1>>		
<<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>		
Phone: <<Doctor:Phone>>		
Fax: <<Doctor:Fax>>		
Signature:		
	Copy of report to:	
Date: <<Miscellaneous:Date>>