THS Statewide Antenatal Referral 
Fax to: (03) 6173 0473 (South) | (03) 6777 5214 (North) | 1800 027 538 (North West)

All Questions and Headings in Bold MUST BE answered
Referring GP Details	Patient Details	
	Name
Provider No.
Practice

Phone (BH)
Phone (AH)
Fax No.	<<Doctor:Name>>
<<Doctor:Provider Number>>
<<Practice:Name>>
<<Practice:Address>>

<<Practice:Phone>>

<<Practice:Fax>>
	Name  
Previous Name
Address  
Phone    

THCI No.
IHI 
DOB	<<Patient Demographics:Full Name>>
<<Patient previous name (if applicable)>>
<<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:Postcode>>
o (H) <<Patient Demographics:Phone (Home)>>   	o (W) <<Patient Demographics:Phone (Work)>> 
o (M) <<Patient Demographics:Phone (Mobile)>>	
Please tick preferred contact number and note preferred time to be contacted 
(Between 9am to 4pm, Mon to Fri)

<<Patient Demographics:IHI>>
<<Patient Demographics:DOB>>	
	Medicare No.
<<Patient Demographics:Medicare Number>>	Ethnicity  <<Patient Demographics:Ethnicity>>
Interpreter Required?  <<Interpreter required?>>   Language (please specify)  <<If interpreter required, which language?>>	
	Existing Referral?
oYes	oNo	Perinatal & infant mental health team (south only) 
Referral indicated? oYes	oNo   Referral completed? oYes		oNo  	
Measurements	History	
BP  <<BP>>	Smoke Hx  <<Clinical Details:Smoking>>	G <<Clinical Details:Gravida>>   P  <<Clinical Details:Parity>>	
Height (cm)  <<Height (cm)>>	Alcohol Hx  <<Clinical Details:Alcohol>><AlcHx>	EDD (by dates)  <<Clinical Details:EDC>>	
Weight (kg)  <<Weight (kg)>>		BMI  <<BMI>>	Drug Hx  <<Drug history>>	EDD (7-12 week scan result)  <<EDD (7-12 week scan result)>>	
Allergies and other Risk factors	
<<Clinical Details:Allergies/Adverse Reactions>>	

Full Clinical Summary on Page 2. Pre-referral information available at http://www.outpatients.tas.gov.au/

Physical Examination to be performed prior to referral. Completed? oYes	oNo (NB Compulsory in the south prior to referral)
Concerns: 
	
Additional Information (please enter)	

GP Initiated Tests (highlight selection/s and type ‘x’)	Maternity Care Requested	
Required Pre-Referral 
o	Full Blood Count
o Blood Group and Antibodies
o Rubella Titre
o Syphilis serology
o MSU
o Hep B and C serology
o HIV Serology
o	Chlamydia (N, NW)
GDM Screening
o Fasting BSL – no risk factors
o GTT – if risk factors/clinical need 
Perform if clinically indicated
o Vit D
o Hb Electrophoresis 
o TFT
o Chlamydia testing(S)	Aneuploidy Screening/Dating 
(Indicate site of scan and date) 
I have arranged:
o Dating scan (if indicated)
o Aneuploidy Screening counselled 
oDeclined/ oconsented      
o 1st trimester screening 
o 2nd trimester screening
o Non-Invasive Prenatal Testing (NIPT)
	(includes scan) 
Screening tests not consented; I have arranged: 
o Morphology scan 
	Letters indicate regional availability
o	GP Share Care (N, S)
o	Midwives Community Clinic (NW, N, S)
o	KYM/Know your Midwife) (S)
o Midwifery Group Practice (N, NW, S)
o TEAM midwives (N)
o Young Mum's Clinic (S) 
o	Drug & Alcohol Pregnancy Service/ 	Complex Care (S)
o Doctors clinic (N, NW, S)
o Obstetric High Risk Clinic (S)
o Antenatal Endocrine Clinic (N,S)
o Undecided

NB Every effort will be made to accommodate requests where risk assessment is appropriate	
Referring Doctors Signature:                                                                  Date: <<Miscellaneous:Date>>	

Please fax completed form to Women’s and Children’s Clinic:
<<Region for referral>>

Current Medications	
<<Clinical Details:Medication List>>
	
Medical History	
<<Clinical Details:History List>>
	
Measurements	

Past Obstetric History	
<<Clinical Details:Past Obstetric History>>
	
Psychiatric History, Diagnosis and Medication	

Social History and Family Support	
<<Clinical Details:Family History>>
<<Clinical Details:Social History>>
	
Investigations	
<<Summary:Investigation Results (Selected)>>