Maternity
     Booking-In
       Referral

	MNHHS Central Patient Intake
Phone: 1300 364 938
Fax: 1300 364 952
Secure electronic transfer to: (MQ40290004P)
Health Link EDI: qldmnhhs 
                     (Attach label or URN:)
	
Please complete patient contact details in full--to allow us to contact your patient promptly	
Information and resources are available at :www.health.qld.gov.au/metronorth/refer/

GP Smart Referrals is the preferred referral method https://practicesupport.org.au/toolbox/referrral-pathways/gp-smart-referrals

Patient details		
Re: 	<PtName>	
Preferred Name:  	<Preferred Name>	
Date of birth: 	<PtDoB>	
Age:	<PtAge>	
Address: 	<PtAddress>  	
Postal Address (if different from software):	<Postal Address if different from software:>	
Home Ph:<PtPhoneH> 	Work Ph: <PtPhoneWk>	
If ineligible for Medicare, provide comments	<If ineligible for Medicare, provide comments>	
Mobile Ph: <PtPhoneMob>		
Medicare Number	<PtMCNo>	
Next of Kin: <Next of Kin Name>	Contact number: <Next of Kin contact number>	
Relationship to patient: <Relationship to patient>		
Interpreter Required? <Interpreter Required?>	Language? <If yes, what is the preferred language?>	
Aboriginal or Torres Strait Islander origin	<Aboriginal or Torres Strait Islander origin>	
Will the Child Identify of Aboriginal or Torres Strait Islander origin? 	<Child Identifies Aboriginal or Torres Strait Islander?>	

Specialty referred to: <Referral To>	
Fax: 1300 364 952     Phone: 1300 364 938	
Secure electronic transfer to: MNHHS CPI (MQ40290004P)	
Tertiary referral:	<Tertiary referral:>	
Reason for tertiary referral:	<If this is a tertiary referral, please provide the reason>	
First antenatal appointment with your GP?	<First antenatal appointment with your GP?>	
Women’s preferred model of care	<Women’s preferred model of care>	

Referring doctor details: <DrName>	
<Practice>	
<UsrAddress>	
Phone:  <UsrPhone>       Fax: <UsrFax>	
Provider No: <DrProviderNo>	

Clinical Details - Current Pregnancy	
LNMP: <LMP>      Certain? <LNMP certain? >       EDD: <EDC> 	
Last cervical screening test: <Pap Smears>	
Reproductive carrier screening undertaken prior to or in early pregnancy: Discussed: <Reproductive carrier screening Discussed> Ordered: <Reproductive carrier screening ordered>	
Parent Carrier Screen: <Parent Carrier Screen (SMA, CF, FXS)>	
Expanded Parent Carrier Screen: <Expanded Parent Carrier Screen>	
Confirmation of pregnancy	
 <Pregnancy Pathology Results>
Screening & Assessment - Current Pregnancy			
Dating scan (if required)	Discussed: <Dating scan (if required) discussed?>	Ordered: <Dating scan ordered?>	
Nuchal translucency + first trimester serum screen (11-13 weeks + 6 days)	Discussed: <Nuchal translucency + first trimester serum screen>	Ordered: <Nuchal translucency ordered?>	
Chorionic Villus Sampling (CVS)	Discussed: <Chorionic Villus Sampling (CVS) Discussed?>	Ordered: <Chorionic Villus Sampling (CVS) ordered?>	
Amniocentesis	Discussed: <Amniocentesis Discussed?>	Ordered: <Amniocentesis ordered?>	
Non-invasive prenatal testing (NIPT)	Discussed: <Non-invasive prenatal testing (NIPT) discussed>	Ordered: <Non-invasive prenatal testing (NIPT) ordered?>	
Morphology diagnostic ultrasound (18-20 weeks)	Discussed: <Morphology diagnostic ultrasound discussed?>	Ordered: <Morphology diagnostic ultrasound ordered>	
Early OGTT/HBA1C indicated (High Risk for GDM)	Discussed: <Early OGTT/HBA1C indicated discussed>	Ordered:<Early OGTT/HBA1C indicated ordered>	
Antenatal screening blood tests ordered via: 	<Antenatal screening blood tests ordered via:>		
I have made a booking to administer dTpa at or after 20 weeks?	<Booking to administer dTpa at or after 20 weeks>		
I have administered the influenza vaccine this pregnancy? 	Given: <Influenza vaccine given this pregnancy?>	Date: <Date influenza vaccine given this preganancy>	
Covid19 vaccination up to date?	Up to date? <Covid19 vaccination up to date?>	Doses completed during pregnancy?<Covid19 doses completed during preganancy>	

Significant obstetric history:
Gravida: <Gravida>	Parity: <Parity>	Miscarriages: <Miscarriages?>	Ectopics: <Ectopics?>	TOP: <TOPs?>	

Past Obstetric History:
  <ObstetricHx>

Significant medical/surgical history: 
  <PMHAll> 

Medication List:
  <CurrentRx> 

Allergies:
  <Reactions>

Investigations:
  <Ix>

Smoking Status:
  <SmkStatus>

Alcohol:
 <AlcHx>

BMI:
 <BMI>

Weight: 
 <Weight>

 Does the patient have mobility issues: 
<Does the patient have mobility issues?>

Other comments: (eg social concerns)
  <Other comments: (eg social concerns)>

Signed electronically  <DrName>
Date: <Date >
MNHHS Maternity Referral v6.6 BP 30042026