Request
Patient details
Name: <PtFullName>	Date of Birth: <PtDoB>	Phone: <PtPhoneMob>	

Patient BMI 40 and under	BMI	
<Patient BMI 40 and under?>	Height: (cms): <Height (cms)>   Weight: (kgs): <Weight (kgs)>   BMI: <BMI>	

My patient has requested assistance with 
Temination of pregnancy <Termination of pregnancy?>
LNMP: <- LNMP>
Formal Blood Group result included: <- Formal Blood Group result included?> (please fax or send via healthlink)	Formal Ultrasound result included: <- Formal Ultrasound result included?> 
Serum bhcg result included: <- Serum bhcg result included>	
Contraceptive Device Insertion requested: <Contraceptive Device Insertion requested?> <- Type of Contraceptive Device requested>
		
IUD removal: <IUD removal?>
<- Type of IUD removal>
Inserted when? <- Date IUD inserted>	Is the string present: <- is the string present?>
If not please sent a copy of the formal ultrasound to inform us of the position of the IUD	

Past Medical History
<SelectedPMH>

Required results for Termination of pregnancy request 
(LNMP, FBG, Formal Ultrasound, Serum bhcg)
<Ix>

Medications
<SelectedRx>

Allergies
<Reactions>
Referrer information
GP Details: <DrDetails>
Provider Number: <DrProviderNo>
Referral date: <TodaysDate>