Request
Patient details
Name: <<Patient Demographics:Full Name>>	Date of Birth: <<Patient Demographics:DOB>>	Phone: <<Patient Demographics:Phone (Mobile)>>	

Patient BMI 40 and under	Patient 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 <<Patient requested temination of pregnancy?>>
LNMP: <<- LNMP>>
Formal Blood Group result included: <<- Formal Blood Group result included?>> (Please fax or send via Healthlink)	Formal Ultrasound performed on: <<- 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?>>
Inserted when? <<- IUD inserted when?>>	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
<<Clinical Details:History List>>

Required results for Termination of pregnancy request 
(LNMP, FBG, Formal Ultrasound, Serum bhcg)
<<Summary:Investigation Results (Selected)>>

Medication
<<Clinical Details:Medication List>>

Allergies
<<Clinical Details:Allergies/Adverse Reactions>>

Referrer information: 
<<Doctor:Full Details>>
<<Miscellaneous:Date (short)>>