Author: Information Technology

AKMR8.1

REFERRAL FOR ANTENATAL CARE AND DELIVERY

Please use ID label or block print

ARMADALE HEALTH SERVICE
REFERRAL FOR ANTENATAL CARE AND DELIVERY

Family Name

UMRN:

Given Names: | DOB:

Completed form, all pathology and scan results to be emailed to Armadale Health Service Referral Office at akg.referrals@health.wa.gov.au preferrable before 14 weeks gestation so that an 18 week midwife appointment can be allocated. Please contact Antenatal Clinic Coordinator
on 9391 2901 for all high risk/urgent referral discussions.

Referral Date: | Name of Referee: | | Signature: | |
Address: | | | Provider number:
PREFERRED MODELS OF CARE:

GP own and public delivery Name of GP-Obs:

Public ANC from 20 wks and public delivery

Midwifery Group Practice - from 12 wks
and public delivery

Private patient under the care of GP-Obs or eligible midwife
Name of Practitioner:

Community Midwifery Program Name of program:
Home Birth	Domino

PATIENT INFORMATION
Given Name(s): | | Family Name: |
Previous Name(s): (eg maiden) | | Date of Birth: |
Address: |
Home Phone: | | Mobile: |
Country of Birth: | | Ethnicity: |
Interpreter required: | Yes	No | Language Spoken: |
Height (cm): | | Weight (kg): |
Medicare number: | | Exp: | LMP: |
Gestation at dating scan | | EDD acc to LMP: |
If twin pregnancy (select type) | Select Type | EDD acc to Scan: |
Influenza Vaccination | Yes	No | Date of vaccination: |
Known medical conditions: |
PREVIOUS PREGNANCY INFORMATION

Pregnancy

Year

Outcome
(select from list)

Name

Gestation (w)

Weight (kg/lb)

1. | | Select From List | | |
2. | | Select From List | | |
3. | | Select From List | | |
4. | | Select From List | | |
5. | | Select From List | | |
ANTENATAL TESTS PERFORMED: (Tick box if done and attach to fax)
REQUIRED ON ALL PATIENTS
Dating Scan | Hepatitis B and C
First trimester screening (11-14w) | HIV
Details scan (18-22w) if already performed or Date Booked: | Syphilis
Rubella Titre
Full Blood Count | Varicella
Blood Group Antibodies | Midstream urine
Chlamydia | Vitamin D level
ONLY IF INDICATED
Ferritin level | Haemoglobinopathy screening
Vitamin B12 level | Glucose screening (High risk patient)
Folate Level | Pap smear
Thyroid Stimulating Hormone (TSH) | Gonorrhoea