REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
MATERNITY SERVICES CLINIC
Template for correspondence about patient with
MATERNAL FETAL MEDICINE

SEND TO Professor David Ellwood (Director of Maternal Fetal Medicine)
PHONE: 07 5687 1149
FAX: 07 5687 6799

B Block Level 1, 1 Hospital Boulevard, Southport 4215
Email: mfm_gcuh@health.qld.gov.au	FROM <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

SEND ONLY BY FAX TO 5687 6799
DO NOT SEND to OUTPATIENT ACCESS AND SCHEDULING CENTRE

SEPARATE REFERRAL FOR ANTENATAL CARE IS REQUIRED TO ANTENATAL CLINIC GCUH

GP Liaison Antenatal Services Mon – Fri 8.00am-4:30pm Phone 07 5687 1525
For urgent pregnancy advice after hours please contact the Maternity Assessment Clinic: 07 5687 1424
Early Pregnancy Assessment Service (less than 16 weeks gestation) Phone: 07 5687 5061 Fax: 07 5687 7892

<<Miscellaneous:Date (long)>>

Dear Professor Ellwood

SECTION 1 Patient details

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
AGE: <<Patient Demographics:Age>>

Gender: <<Patient Demographics:Gender>>
Address:<<Patient Demographics:Full Address>>
Home Ph: <<Patient Demographics:Phone (Home)>>
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>
Medicare Number*: <<Patient Demographics:Medicare Number>>  (*Medicare ineligible patients will incur a consultation fee)
	Next of Kin/Alternative Contact: <<Patient Demographics:Next of Kin>>
Next of Kin/Alternative Contact Ph: <<Patient Demographics:Next of Kin Phone>>
Does patient identify as Aboriginal and/or Torres Strait 
Islander: <<Patient Demographics:ATSI>>
Interpreter required: <<Interpreter required>>
If yes, specify language: <<If yes, specify language>>	

SECTION 2 Reason for referral 

Main reason for this referral or relevant history, clinical examination findings and treatment to date:

Tertiary Ultrasound Assessment: <<Tertiary Ultrasound Assessment>>
Fetal Growth and Wellbeing: <<Fetal Growth and Wellbeing>>
Multiple Pregnancy: <<Multiple Pregnancy>>
Cervical and Placental Assessment: <<Cervical and Placental Assessment>>
First Trimester Combined Screening (high risk patients only): <<First Trimester Combined Screening>>
Morphological Assessment in High Risk Pregnancy: <<Morphological Assessment in High Risk Pregnancy>>
Consultation for High Risk for CFTS: <<Consultation for High Risk for CFTS>>
Diagnostic testing of Amniocentesis for CVS (include blood group): <<Testing of Amniocentesis for CVS (incl blood group)>>

Paste or type relevant history, clinical examination findings and treatment to date if required	

SECTION 3 Mandatory clinical information

Gravida - total number of pregnancies: <<Gravida - total number of pregnancies>>
Parity - total number of births: <<Parity - total number of births>>
Last menstrual period: <<Last menstrual period>>
Miscarriage/TOP:  <<Miscarriage/TOP>>

Current blood pressure: <<Current blood pressure>>
Patient's BMI: <<Specify patients BMI>>

Estimated date of delivery:  <<Estimated date of delivery>>

SECTION 4 Investigations 

PREVIOUS ULTRASOUND REPORTS ARE REQUIRED WITH THIS REFERRAL

Ultrasound scans: <<Ultrasound scans>>

<<Summary:Investigation Results (Selected)>>

SECTION 5 Social factors and impact on the patient

Consider the impact on employment/education; activities of daily life; ability to care for others; personal safety/frailty;
other factors. Please paste or type relevant information.

	

SECTION 6 Medical history including co-morbidities and previous surgical interventions

Alcohol: <<Clinical Details:Alcohol>>
Smoking: <<Clinical Details:Smoking>>

<<Clinical Details:History List>>

<<Operation:CoMorbidities>>

<<Operation:Previous Procedures>>

Allergies: <<Clinical Details:Allergies/Adverse Reactions>>

Current prescribed medications: <<Clinical Details:Medication List>>

SMOs/VMOs in this Specialist Service	

Professor David Elwood (Director of MFM)	Dr Adriana Olog  	 Dr Justin Nasser 	

General information about referrals	

Queensland Clinical Prioritisation Criteria (CPC) are available for this condition and specialty. These criteria can be viewed by visiting: https://cpc.health.qld.gov.au/

Referral Templates that outline clinical information and investigations required to safely refer your patient into Gold Coast Health can be accessed via: https://www.healthygc.com.au/Health-Care-Professionals/Referral-Templates.aspx