Maternity
     Booking-In
       Referral

	MNHHS Central Patient Intake
Phone: 1300 364 938
Fax: 1300 364 952
Secure electronic transfer to: (MQ40290004P)

                     (Attach label or URN:)
	
Please complete patient contact details in full--to allow us to contact your patient promptly	
Information and resources are available at :www.health.qld.gov.au/metronorth/refer/
Patient details		
Re: 	<<Patient Demographics:Full Name>>	
Preferred Name:  	<<Preferred Name>>	
Date of birth: 	<<Patient Demographics:DOB>>	
Age:	<<Patient Demographics:Age>>	
Address: 	<<Patient Demographics:Address Line 1>> <<Patient Demographics:Address Line 2>> <<Patient Demographics:Address Line 3>> <<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>	
Postal Address (if different from above):	<<Postal Address if different from above:>>	
Home Ph:<<Patient Demographics:Phone (Home)>> 	Work Ph: <<Patient Demographics:Phone (Work)>>	
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>		
Medicare Number	<<Patient Demographics:Medicare Number>>	
Next of Kin: <<Next of Kin Name>>	Contact number: <<Next of Kin contact number>>	
Relationship to patient: <<Relationship to patient>>		
Interpreter Required? <<Interpreter Required?>>	Language? <<If yes, what is the preferred language?>>	
Aboriginal or Torres Strait Islander origin	<<Aboriginal or Torres Strait Islander origin>>	
Will the Child Identify of Aboriginal or Torres Strait Islander origin? 	<<Child Identifies Aboriginal or Torres Strait Islander?>>	

Specialty referred to: <<Referral To>>	
Fax: 1300 364 952     Phone: 1300 364 938	
Secure electronic transfer to: MNHHS CPI (MQ40290004P)	
Tertiary referral:	<<Tertiary referral:>>	
Reason for tertiary referral:	<<If this is a tertiary referral, please provide the reason>>	

Referring doctor details: <<Doctor:Name>>	
<<Practice:Name>>	
<<Practice:Address>>	
Phone: <<Practice:Phone>>          Fax: <<Practice:Fax>>	
Provider No: <<Doctor:Provider Number>>	

Clinical Details - Current Pregnancy	
LNMP: <<Clinical Details:LNMP>>      Certain? <<LNMP certain? >>       EDD: <<Clinical Details:EDC>> 	
Last pap smear: <<Clinical Details:Pap Smears>>	

Screening & Assessment - Current Pregnancy			
Dating scan (if required)	Discussed: <<Dating scan (if required) discussed?>>	Ordered: <<Dating scan ordered?>>	
Nuchal translucency + first trimester serum screen (11-13 weeks + 6 days)	Discussed: <<Nuchal translucency + first trimester serum screen>>	Ordered: <<Nuchal translucency ordered?>>	
Chorionic Villus Sampling (CVS)	Discussed: <<Chorionic Villus Sampling (CVS) Discussed?>>	Ordered: <<Chorionic Villus Sampling (CVS) ordered?>>	
Amniocentesis	Discussed: <<Amniocentesis Discussed?>>	Ordered: <<Amniocentesis ordered?>>	
Non-invasive prenatel testing (NIPT)	Discussed: <<Non-invasive prenatel testing (NIPT) discussed>>	Ordered: <<Non-invasive prenatel testing (NIPT) ordered?>>	
Morphology diagnostic ultrasound (18-20 weeks)	Discussed: <<Morphology diagnostic ultrasound discussed?>>	Ordered: <<Morphology diagnostic ultrasound ordered>>	
Antenatal screening blood tests ordered via: 
(please send copies with referral)	<<Antenatal screening blood tests ordered via:>>		

Significant obstetric history:
Gravida: <<Clinical Details:Gravida>>	Parity: <<Clinical Details:Parity>>	Miscarriages: <<Miscarriages?>>	Ectopics: <<Ectopics?>>	TOP: <<TOPs?>>	

Past Obstetric History:
  <<Clinical Details:Past Obstetric History>>

Significant medical/surgical history: 
  <<Clinical Details:History List>>

Medication List:
  <<Clinical Details:Medication List>>

Allergies:
  <<Clinical Details:Allergies>>

Investigations:
  <<Summary:Investigation Results (Selected)>>

Smoking Status:
  <<Clinical Details:Smoking>>

Alcohol:
  <<Clinical Details:Alcohol>>

BMI:
 <<BMI>>

Weight: 
<<Clinical Details:Measurements>>

 Does the patient have mobility issues: 
<<Does the patient have mobility issues?>>

Other comments: (eg social concerns)
  <<Other comments: (eg social concerns)>>

Signed electronically  <<Doctor:Name>>
Date: <<Miscellaneous:Date (short)>>

MNHHS Maternity Referral v6.3 MD 07042021