Maternity Booking Referral Letter
CANTERBURY HOSPITAL MATERNITY SERVICES
•	This referral has TWO sides
•	It would be appreciated if you could complete both sides of the referral an antenatal examination form	Affix Patient ID Label Here
(Hospital Use only)	
•	Please give completed form and copies of any results to the woman to bring to her appointment with the antenatal clinic.	

Options of Referral
£ Antenatal Clinic      £ Midwifery Group Practice     £ Midwives Clinic     £ GP Shared Care

Woman to complete this section
Surname: <<Patient Demographics:Surname>>	Given Names: <<Patient Demographics:First Name>>	
Previous/ Maiden Name:	Occupation: <<Patient Demographics:Occupation>>	
Date of Birth:<<Patient Demographics:DOB>>	Medicare No: <<Patient Demographics:Medicare Number>>	Exp Date:	
Marital Status: <<Patient Demographics:Marital Status>>	Country of Birth:	
Language used at home:	Interpreter needed:             £ Yes                     £ No	
                          Home Address	                          Person to Contact	
Street: <<Patient Demographics:Address Line 1>>	Name:	
	Relationship:	
Suburb: <<Patient Demographics:City>>	Street:	
State: <<Patient Demographics:State>>	P/Code: <<Patient Demographics:Postcode>>	Suburb:	
Phone no : (h) <<Patient Demographics:Phone (Home)>>	State:	P/Code:	
(mob)<<Patient Demographics:Phone (Mobile)>> 
(wk) <<Patient Demographics:Phone (Work)>>	Phone No:	

              USEFUL PHONE NUMBERS
Canterbury Hospital
Main Switch		9787 0000
Antenatal Clinic 	9787 0560
Appointments Mon- Fri 8am – 4.30pm
Birthing Unit		9787 0555

Royal Prince Alfred Hospital
Main Switch		95156111
Maternity Appointments      95157101	               Canterbury Hospital

Clinic operating hours - 08:30am to 4:00pm 
Monday to Friday excluding Public Holidays Tel : (02) 9787 0250 or (02) 9787 0560
Fax: (02) 9787 0431.	

DOUBLE SIDED FORM, PLEASE COMPLETE THE MEDICAL EXAMINATION AND INVESTIGATION ON REVERSE OF THIS PAGE.  If you consider this referral to be Urgent please call the Antenatal Clinic (PH:  9787 0250 or 9787 02560 and ask for the Clinic Midwife)       

Maternity Booking Referral Letter
               ANTENATAL EXAMINATION & INVESTIGATIONS
LMP: _____________ EDB:_______________ GRAVIDA: _________________PARITY: _____________	

Investigations (tick if attended)

Attended	

1	
Blood Group & Antibody screen	

2	
Haemoglobin	

3	
VDRL	

4	
Rubella IgG	

5	
Hep B surface antigen	

6	
Hep C (anti HCV), after discussion	

7	
HIV ( after discussion)	

	Dear Doctor, 
Early Referral for Genetic testing  - 
If Genetic testing (with Counselling) is required for this woman (eg. age over 35yrs or family history of genetic disease), please arrange before 12 weeks gestation. If this is not possible please ensure timely referral to  the antenatal clinic. 
Thank you.	
8	Thalassaemia (HbEPG)			Yes	No	
9	Varicella IgG		Genetic Counselling provided			
10	Glucose Challenge Test		Referred for Genetic Counselling			
11	Glucose Tolerance Test		Genetic Testing or Screening			
12	MSU		Nuchal Translucency plus bloods			
13	Ultrasound 18-20 wks FAS		CVS			
14	PAP smear		Amniocentesis			
15	Low Vaginal swab (as required)		Declined			
16	Other		Not indicated			

Cardiovascular system 	BP ___/___ at ____ weeks gestation 	Allergies: <<Clinical Details:Allergies>>	
 Respiratory system		Current Medications: (over page)	
Abdominal examination	

Thyroid	

Breast Examination	

Pre/ early pregnancy weight	

Problems in current pregnancy 	

Other Findings	

	

GP Stamp/details: 	

<<Doctor:Name>>	

<<Doctor:Address>>	

Phone number:	
<<Doctor:Phone>>	

Fax number:	
<<Doctor:Fax>>	

Provider No.	
<<Doctor:Provider Number>>	

Signature

	
Date:
<<Miscellaneous:Date>>	

	Medical History       Yes            	 No
Cardiac                        ð		ð                     
Asthma                        ð           		ð            
Hypertension             ð		ð                     
Endocrine                   ð                       	ð
Mental Illness            ð                  	ð
Renal                            ð		ð                    
Epilepsy      	            ð		ð                      GIT	            ð		ð
Smoker	            ð		ð
STIs	            ð		ð
Other

Family History                         Yes                  No
Diabetes   	                            ð 	ð  
Hypertension	                            ð 	ð    
Congenital Abnormalities	  ð 	ð                     
Twins		  ð 	ð                     
Other	
Please note: It may require more than one visit to the GP’s surgery to complete this form.
Please return this form to the woman

Current Medications
<<Clinical Details:Medication List>>