Patient Information	
Name:	<PtFullName>	
Address:	<PtAddress>

Contact Number:	<PtPhoneH>	

Reason for Referral	
Heavy bleeding (changing pad/ tampon each hour)
for more than 7 days, clots larger than 50 cents	<Heavy Bleeding More than 7 Days clots larger than 50c>	
Ultrasound findings of possible polyp, submucosal fibroid, or cystic changes	<Ultrasound findings of possible polyp, submucosal fibroid, or cystic changes>	
Irregular bleeding with normal ultrasound	<Irregular bleeding with normal ultrasound>	
Post menopausal bleeding with endometrial thickness (ET) > 4mm	<Post menopausal bleeding with endometrial thickness (ET) gt 4mm>	
Post menopausal bleeding on HRT
with (ET) > 7mm	<Post menopausal bleeding on HRT with ET gt 7mm>	
Post menopausal with no bleeding and (ET) > 11mm	<Post menopausal with no bleeding and (ET) gt 11mm>	
Post menopausal irregular bleeding on Tamoxifen	<Post menopausal irregular bleeding on Tamoxifen>	
IUD Insertion under general anaesthetic	<IUD Insertion under general anaesthetic>	

History	
<SelectedPMH>

Current medications/anticoagulants	
<SelectedRx>

Lifestyle/referral requirements	
Patient Weight (kg)	<patient weight (kg)>	Patient Height (cm)	<patient height (cm)>	

Referring General Practitioner	
Print Name:	<DrName>	Provider No:	<DrProviderNo>	
Signature:		Date:	<TodaysDate>	

Funding Details	
Health Fund:	<PtInsFund>	Membership No:	<PtInsNo>	
Self Funding	<self funding>	Medicare No:	<PtMCNo> / <PtMCLine>	
		DVA No:	<PtDVANo>	

Pelvic ultrasound scan & report/Other Investigations - Select Relevant	
<Ix>