Date: <DayAndDate>

Is this patient suitable for GP Shared Care? <Is this patient suitable for GP Shared Care?> <If the patient is NOT SUITABLE for GP Shared Care, it's because...>

ANC Consultants:
<Referring for care at [ST GEORGE HOSPITAL]> STG (Drs T.Miller, G.Davis, A.Henry, S.Kanitkar, K.Kavanagh-Patel, C.Duong)
<Referring for care at [THE SUTHERLAND HOSPITAL]> TSH (Drs A.Zuschmann, D.Conrad, A.Harris, N.Peters, K.King, D.Krishnan, C.Krishnan)

GP Details*:
<DrName>
<DrAddress>
Provider Number: <DrProviderNo>
Tel: <DrPhone> Fax: <DrFax>
GP Shared Care provider? <Are you a GP Shared Care Provider?>

Signed by GP: _________________________

*If the collaborating GP is a Registrar, please detail the name and provider number of the supervising GP: <If you are a GP Registrar, please detail the name and provider number of your supervising GP>

Patient Details:
<PtFullName>
DOB: <PtDoB>
<PtAddress>
Tel: <PtPhoneMob>
Email: <PtEmail>

Patient Declaration:
<Does the patient consent to their personal and health information being shared between you and the hospital clinic?> I agree to my personal and health information being shared between my GP and the hospital clinic(s) for the provision of my healthcare.
			
Signed by patient: _________________________

______________________________________________________________________________________________

Current Pregnancy:
Maternal age: <PtAge>; <Gravida Para Miscarriage TOP>; LMP: <LMP>; EDC: <EDC> determined by <EDC determined by...>
Complications so far: <Complications in pregnancy so far?> <If YES, details of COMPLICATIONS SO FAR>
Screening/imaging results so far: <Screening/imaging results so far (enter details if applicable)>
Smoking/Vaping: <Smoking/Vaping?> <If YES, details of SMOKING/VAPING>
Alcohol: <Alcohol consumption?> <If YES, details of ALCOHOL CONSUMPTION>
Other substance use: <Other recreational substance use?> <If YES, details of RECREATIONAL SUBSTANCE USE>
Allergies: <Allergies?> <If YES, details of ALLERGIES>
Multivitamin/CAM/over-the-counter treatments: <Multivitamin/CAM/over-the-counter treatments>
Current prescription medications: <SelectedRx>

Obstetric/Gynaecological History:
<Obstetric/Gynaecological History>
<Is there a history of birth-related trauma?>

Other Personal Medical History:
<SelectedPMH>

Date of last CST on record: <Date of last CST on record>, result: <Result of last CST on record>

Family History:
<Any family history of...? (select all that apply)>
Details: <Details of FAMILY HISTORY (enter or leave as "n/a")>

Relevant Social History:
Interpreter needed? <Interpreter needed?> <If YES, the patient's PREFERRED LANGUAGE is>
<Relevant social history>
______________________________________________________________________________________________

Examination at <Gestation at the time of observations and physical assessment> weeks’ gestation:
<Observations>
Physical assessment has included: <Physical assessment has included (edit as needed)>
Relevant physical findings: <Relevant physical findings (if applicable, or leave as "nil significant")>
______________________________________________________________________________________________

<Please tick this box if there are special circumstances for which a verbal handover between the GP and the hospital clinic early in this pregnancy would be beneficial and important> Please tick this box if there are special circumstances for which a verbal handover between the GP and the hospital clinic early in this pregnancy would be beneficial and important.
______________________________________________________________________________________________

Has first trimester screening been arranged? <Has first trimester screening been arranged?>
Is this patient on an appropriate prenatal supplement? <Is this patient on an appropriate prenatal supplement?>
Is an early Oral Glucose Tolerance Test indicated? <Is an EARLY Oral Glucose Tolerance Test indicated?>
Is low dose aspirin therapy indicated? <Is low dose aspirin therapy indicated?>
Is additional folate supplementation indicated? <Is additional folate supplementation indicated?>
Has a DV screen been performed? <Has a DV screen been performed?>
Does this patient have an active MyHealthRecord? <Does this patient have an active MyHealthRecord?>
______________________________________________________________________________________________

The following tests have been ordered:
<The following routine tests have been ordered (select all that apply)>. <Also these common optional tests have been ordered (select all that apply)>

Pathology company: <Pathology company>

<Were the antenatal pathology results copied to the Antenatal Clinic?> Results copied to Antenatal Clinic
______________________________________________________________________________________________

 INFORMATION FOR PATIENTS

Please bring this completed referral form with you when you attend your first antenatal appointment at the hospital. Have you completed the online booking form yet? If not, please follow the relevant link below. You’ll receive an appointment confirmation letter by email. There may be a period of wait between submitting your form online and receiving a reply email.

	The Sutherland Hospital			St George Hospital