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: 	<<Patient Demographics:Full Name>>	
Preferred Name:  	<<Preferred Name>>	
Date of birth: 	<<Patient Demographics:DOB>>	
Age:	<<Patient Demographics:Age>>	
Address: 	<<Patient Demographics:Address Line 1>> <<Patient Demographics:Address Line 2>> <<Patient Demographics:Address Line 3>> <<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>	
Postal Address (if different from above):	<<Postal Address if different from clinical file>>	
Home Ph:<<Patient Demographics:Phone (Home)>> 	Work Ph: <<Patient Demographics:Phone (Work)>>	
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>		
Medicare Number	<<Patient Demographics:Medicare Number>>	
If ineligible for Medicare, provide comments	<<If ineligible for Medicare, provide comments>>	
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?>>	
Patient identifies as having a refugee background?	<<Patient identifies as having a refugee background?>>	

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: <<Doctor:Name>>	
<<Practice:Name>>	
<<Practice:Address>>	
Phone: <<Practice:Phone>>          Fax: <<Practice:Fax>>	
Provider No: <<Doctor:Provider Number>>	

Clinical Details - Current Pregnancy	
LNMP: <<Clinical Details:LNMP>>      Certain? <<LNMP certain>>       EDB: <<Clinical Details:EDC>> 	
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 (Please send results with referral)<<Confirmation of pregnancy?>>	
Current Pregancy - Single or multiple?  <<Currently Pregnancy - Single or Multiple?>>	
 <<Clinical Details:Pregnancy Pathology Results>>
Screening & Assessment - Current Pregnancy			
Last cervical screening test: 	<<Clinical Details:Pap Smears>>		
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>>		

Immunisation History:
Covid19 vaccination up to date?	Up to date? <<Covid19 vaccination up to date?>>	Doses completed during pregnancy?<<Covid19 doses completed during pregnancy>>	
I have administered the influenza vaccine this pregnancy? 	Given: <<Influenza vaccine given this pregnancy?>>	Date: <<Date influenza vaccine given this pregnancy>>	
I have made a booking to administer dTpa at or after 20 weeks?	<<Booking to administer dTpa at or after 20 weeks>>	

Significant obstetric history:
Gravida: <<Clinical Details:Gravida>>	Parity: <<Clinical Details:Parity>>	Miscarriages:  <<Miscarriages?>>	Ectopics: <<Ectopics?>>	Still Birth:
<<Still Birth?>>	TOP: <<TOPs?>>	

Past Obstetric History:
  <<Clinical Details:Past Obstetric History>>

Significant medical/surgical history: 
  <<Clinical Details:History List>>

Medication List:
  <<Clinical Details:Medication List>>

Allergies:
  <<Clinical Details:Allergies>>

Investigations:
  <<Summary:Investigation Results (Selected)>>

Smoking Status:
  <<Clinical Details:Smoking>>

Alcohol:
  <<Clinical Details:Alcohol>>

BMI:
 <<BMI>>

Weight: 
<<Clinical Details:Measurements>>

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

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

Signed electronically  <<Doctor:Name>>
Date: <<Miscellaneous:Date (short)>>

MNHHS Maternity Referral v6.6 MD 30042026