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                          OR
FAX:  07 5687 6799

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

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.NOK Name
Next of Kin/Alternative Contact Ph: Patient Demographics.NOK Mobile Phone
Does patient identify as Aboriginal and/or Torres Strait Islander: Does pt identify as 
Interpreter required: Interpreter required
If yes, specify language: If yes, specify lang	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: Specify reason

Tertiary Ultrasound Assessment: Tertiary Ultrasound 
Fetal Growth and Wellbeing: Fetal Growth and Wel
Multiple Pregnancy: Multiple Pregnancy
Cervical and Placental Assessment: Cervical and Placent
First Trimester Combined Screening (high risk patients only): First Trimester Comb
Morphological Assessment in High Risk Pregnancy: Morphological Assess
Consultation for High Risk for CFTS: Consultation for Hig
Diagnostic testing of Amniocentesis for CVS (include blood group): Diagnostic testing o

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 details
Parity - total number of births: Parity details
Last Menstrual Period: LMP
Miscarriage/TOP: Miscarriage/TOP

Current blood pressure: Blood Pressure
Patients BMI: BMI details

Estimated date of delivery: Est date of delivery

SECTION 4 Investigations

PREVIOUS ULTRASOUND REPORTS ARE REQUIRED WITH THIS REFERRAL

Ultrasound scans: Ultrasound scans

Clinical Details.Result List (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.Problem List (Current) With Comments

Clinical Details.Problem List (Resolved) With Comments

Allergies: Clinical Details.Allergies

Current prescribed medications: Clinical Details.Medications - Current Regular

SMOs/VMOs in this Specialist Service	

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