<<Miscellaneous:Practice Letterhead>>

Dear Launceston Women’s Health Clinic (LWHC),

Thank you for seeing <<Patient Demographics:Full Name>> for consideration of MTOP.

DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Address>>, <<Patient Demographics:City>>, <<Patient Demographics:Postcode>> 
Mobile number: <<Patient Demographics:Phone (Mobile)>>

Medicare Number: <<Patient Demographics:Medicare Number>>   Concession Card number: <<Patient Demographics:Pension Number>>

LNMP: <<Clinical Details:LNMP>>

Current Gestation (dates): 

Current Gestation (USS): 

Allergies: <<Clinical Details:Allergies/Adverse Reactions>>
Medications: <<Clinical Details:Medication List>>
Past History: <<Clinical Details:History List>>
Obstetric History: <<Clinical Details:Past Obstetric History>>

Contraception choice post MTOP if applicable:

Investigations to be organised:
Please request copies of pathology tests and Imaging to be electronically sent to LWHC. 

•   FBC, Blood Group, Quantitative HCG
•   Dating Scan: Book the USS appointment. Mark request form “pregnancy options dating scan”
•   Swabs: Self obtained lower vaginal swab and first pass urine collection for chlamydia

Print this document to give to your patients:  
LWHC Patient Information on Medication Termination of Pregnancy on MTOP 
•	Located on LWHC website: www.launcestonwhc.com.au/health-professionals/

Referring Doctor Details: <<Doctor:Name>>
Referring Doctor Signature: _____________________________
Date: <<Miscellaneous:Date>>

Women wishing to have an MTOP need to have an ultrasound and pathology tests done and the results of those tests need to be conveyed to the MTOP prescribing doctor with enough time for medication to be prescribed before the 63 day cut off. 
LWHC will contact the patient on receipt of this referral.