Maternity Care Referral Form
Fax referral to:
Djerriwarrh Health Service (DjHS) (Bacchus Marsh & Melton Regional Hospital)
Mercy Hospital for Women - Heidelberg
Werribee Mercy Hospital
Western Health (WH) (Sunshine Hospital)
Fax: 9746 0668
Fax: 8458 4205
Fax: 8754 3467
Fax: 8345 1691
This form constitutes a valid referral to Djerriwarrh Health Service (Bacchus Marsh & Melton Regional Hospital), Mercy
Hospital for Women – Heidelberg, Werribee Mercy Hospital and Western Health (Sunshine Hospital), and provided all
requested details are complete.
Patient Details
Referring Doctor Details
First Name:
Last Name:
Name:
Previous last name:
Practice Name:
Date of birth:
Practice address:
Address:
Suburb:
Postcode:
Ph:
Suburb:
Postcode:
Fax:
Home phone:
Mobile:
Provider number:
Medicare no.:
Date:
Yes No
Yes No
ATSI status mother:
Interpreter required:
Specify language:
Country of origin:________________Year of arrival if known:_____________
Previous Mercy patient:
Yes NoPrevious WH patient:
Yes No
Shared Care
I am able to provide shared care to the patient:
Previous DjHS patient:
Yes No
Comment:
Current Obstetric History
LNMP:
Estimated delivery date:
Gravida:
Height:
Parity:
cm
Known multiple pregnancy:
Weight:
kg
Last PAP test: date & result
Yes No 
BMI*:
*must be included to enable triage and booking
Female circumcision:
Yes No
Past Obstetric History Tick if applicable

Previous severe pre-eclampsia

Mid trimester loss OR miscarriage x 3 or
more
 Previous small baby <2800g
 Previous fetal abnormality (specify)
 Previous preterm birth <35 weeks
 Previous Caesarean, how many_____
( specify gestation____)
 Still birth
 Other (specify)
 Placental abruption
 Rhesus isoimmunisation


Gestational diabetes
PPH >= 1000mls
Past Medical and Surgical History
Social History
Patient name
Referring doctor
Date
Risk Factors Relevant to Pregnancy Tick if applicable



Diabetes pre pregnancy
Heart disease
Asthma requiring admissions or
oral steroids within past 12 months



Epilepsy
DVT or pulmonary embolus



Cervical surgery
Anaemia
Previous cone biopsy /2 or more LLETZ procedures
Thalassemia / haemoglobinopathy

Psychiatric disorders

Hepatitis B or C

High blood pressure/or on medication

Renal disease

SLE

Thyroid disease



Smoking
Family history of genetic disease (specify)__________________________________________________________
Alcohol and other drugs (specify)___________________________
Investigations /Test Results Provide results to your patient to bring to her first appointment
Pathology Provider ________________________________________
Required tests/investigations:
 FBE
 HIV serology
 Blood group and antibodies
 MSU / urinalysis
 Rubella
 Ferritin
 Hepatitis B
 Syphilis serology
 Hepatitis C
 Thalassemia testing/ Hb electrophoresis
 Morphology 20 week Ultrasound (please provide details of ultrasound provider)
Please note for Werribee Mercy and Sunshine Hospital low-risk women will need to see their GP to order 20 week morphology scan,
as these are not routinely available at the hospital. Early requests made directly to imaging department may be accommodated for
Mercy Hospital for Women with GPs being advised of outcome depending on capacity.
Consider:
 Dating ultrasound
 Vitamin D
 Chlamydia
 GTT at 16 weeks: if past GDM, PCOS, BMI>35, Family history of diabetes, previous baby >4.5kg
Aneuploidy Screening
Aneuploidy screening options have been discussed with the patient:
 Yes  No
If yes:
 First Trimester Combined Screen
(please provide details of ultrasound provider)
 Second Trimester MSST
 Non-invasive Prenatal screening using cell free DNA (please provide details of provider)
The patient has declined aneuploidy screening:
 Yes
 No
Attach Relevant Investigations
Medications (please note if taken first trimester folate and iodine)
Allergies
Other Relevant Information
Doctor’s signature:
Date:
Appointment details will be sent to referring GP and patient.
IMPORTANT NOTICE – PRIVILEGED AND CONFIDENTIAL MESSAGE
This facsimile transmission is intended for the exclusive use of the person or hospital to which it is addressed and may contain information that by law is privileged or
confidential. If the reader of the facsimile transmission is not the intended recipient, you are hereby notified that any disclosure, distribution of copying of this transmission is
prohibited by law, and the contents must be kept strictly confidential. If you have received this transmission in error, kindly notify us immediately and return the original to us at
the above address.
Patient name
Referring doctor
Date