REQUEST for OUTPATIENT APPOINTMENT
to King Edward Memorial Hospital
Please make an appointment for this patient to attend: (please check)
Obstetric
Gynaecology
Diagnostic Imaging/Ultrasound Only
Menopause
Fertility
CVS/Amniocentesis only
Oncology
Genetic
Other:
Next of Kin/Guardian:
Family name:
Relationship:
Family name:
First Name (s):
Has the patient previously been seen by this hospital?
Maiden Name:
Retained:
First Name:
Yes
Yes
No
No
Name Registered:
Year of last attendance:
Is an interpreter required?
Address:
Yes
No
If yes, language / dialect:
Telephone No.:
Home:
Work:
Postcode:
Mobile
Birth Date:
/
/
Marital Status:
Age:
BMI (required for all referrals):
M
W
D
If BMI unknown, please include: weight (kg):
Sep
Defacto
height (m):
Country of Birth:
Medicare Number.:
Ref:
S
Expiry:
Referring doctor stamp and signature (compulsory for Diagnostic Imaging requests)
Name:
Phone:
Address:
If other than Obstetric Patient PTO 
If Obstetric Patient:
We would like to share antenatal care with you, both before and after the first clinic visit (usually at 19 weeks).
I do not wish to be involved in shared care
Gravida:
Parity:
LMP:
EDD (by dates):
EDD (by ultrasound)
Please forward photocopies or arrange copies to be sent to KEMH of results of tests listed below.
Check () beside the test if you have, or will, arrange the test.
Full Blood Picture
Pap (within 2 years)
Group and atypical antibodies
Midstream Sterile Urine
Early dating ultrasound (if dates uncertain)
HIV
Rubella antibodies
Hep B surface antigen
Syphilis antibodies
Fetal anatomy U/S (18 to 20 weeks)
Chlamydia
Glucose tolerance test routine at 24-28 weeks
To be done at 1st visit to GP if high risk for GDM
Hep C antibodies
1st trimester screen (11 to 13 weeks) or
Other:
maternal serum screening (15 to 17 weeks)
Indicate specialist service/s that you believe need to see this patient at KEMH before 19 weeks, please state
reason over page.
Adolescent
Ultrasound
Drug and Alcohol
Diabetes
Dietician
Genetic
Medical
Social Work
Psychological Medicine
Maternal Fetal Medicine (if high risk )
Other – Please specify
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Referral Letter
Please return this form to:
King Edward Memorial Hospital, 374 Bagot Road, Subiaco WA 6008
or by fax to: 9340 1031
Please note: your patient may be referred to a health service closer to home if they do
not require tertiary care.
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