Gynaecology Clinic Referral Form V13

GYNAECOLOGY CLINIC REFERRAL LETTER
CIRCLE PERSONAL DETAILS:

which
staff Name: ____________________________________ Medicare No: _____________________________
specialist/
VMO Date of Birth: ___/___/_____ Telephone No: _______________________________________________
---- Address: _______________________________________________________
Westmead: Email: ___________________ Interpreter needed: No:  Yes: if yes specify language
Dr Anpalagan

Dr Arrage
REASON FOR REFERRAL:
A/Prof W. Chan
Dr A. Chen  Menstrual problem (heavy menstrual, irregular / postcoital or postmenopausal bleeding)
Dr Goh  Ultrasound finding (polyp-fibroid)
Dr Hu APPOINTMENT WILL NOT BE OFFERED

 Ultrasound finding (ovarian cyst)
WITHOUT RESULTS ATTACHED
Dr Kapurubandara  Pelvic pain / endometriosis
Dr Nikam - last CST result attached: No Yes
 Incontinence and voiding problem Please make sure to attach all relevant
Dr Samiei-Sarir
investigations such as ultrasound & pathology
Dr Sivananthan  Prolapse
results.
Dr Tong  Vulval itch / pain and skin problem Please also advise your patient to bring films of all
Blacktown: ultrasound and CT scans to their visit so that we
 Infertility
Dr Atkinson can review them.
Dr Bates  Other (specify)
Dr Blumenthal FOR FERTILITY PATIENTS ONLY: PLEASE COMPLETE PARTNER DETAILS BELOW
Dr Bradford
Name: ________________________Male/Female/Other: _________Medicare No: __________________
Dr Chan
Date of Birth: ___/___/_____ Telephone No: _______________________________________________
Address: ___________________________________________________________________________
Dr Gerges
Dr Gomez
Email: _____________________________ Interpreter needed: No:  Yes:  if yes specify language
Dr Maddox
Dr Mane
FOR ALL PATIENTS:
Dr Martin Please provide a short summary of significant symptoms and attach the relevant investigations
Dr Perera (Pelvic ultrasound / any pathology / latest cervical screening result -  self-collect  clinician collect)
Dr Santiagu
Auburn:
Dr Ardalic
Relevant co-morbidities / past medical and surgical history
Dr Bakal
Dr Inglis
Dr Maravar
Dr Mohan Medications and allergies
Dr Noori
Dr Sivananthan
Dr Su REFERRING DOCTOR’S DETAILS:
or Name: ______________________________________________________________
Auburn Clinic
Consultants
Address:_____________________________________________________________
Phone: _____________________ Fax:_______________________ Provider No: __________________
GP signature: _________________________ Date: _____________________

PATIENT WILL RECEIVE AN APPOINTMENT LETTER FROM HOSPITAL WITH THE DATE & TIME OF THEIR APPOINTMENT
Please contact the relevant hospital for enquiries regarding your appointment.
Westmead: Fax to 8890 5198 or Email: [email protected]
Blacktown: HealthLink eReferral only. For further details, visit:
https://www.wslhd.health.nsw.gov.au/information-for-health-care-professionals/ereferals
Blacktown only contact (Gynae Nurse 0437174682 or 8670 8356)
Auburn: Fax to 8759 3246 or Email: WSLHD-Auburn-Women’[email protected]
V13 23/01/2024
GYNAECOLOGY CLINIC REFERRAL LETTER
out-of-pocket
costs incurred.
SPECIALITY GYNAECOLOGY CLINIC INFORMATION

Specialty Gynaecology Clinics Blacktown Hospital
General Gynaecology Clinic - Gynaecologists:

• Dr Chan
• Dr Gomez
• Dr Maddox
• Dr Mane
• Dr Santiagu
See Western Sydney HealthPathways -Non-urgent Gynaecology Assessment for referral details
https://westernsydney.communityhealthpathways.org/41408.htm
Contraception Clinic - Gynaecologist:
• Dr M Martin
See Contraception Clinic referral form - https://shorturl.at/drIM9
See Western Sydney HealthPathways Contraception Referrals for more referral details
https://westernsydney.communityhealthpathways.org/81919_1.htm
Endo-Gynaecology Clinic - Gynaecologist:
• Dr B Gerges - Use the General Gynaecology Clinic Referral form.
Colposcopy Clinic - Gynaecologists:
• Dr N Blumenthal
• Dr K Perera
See Colposcopy Clinic Referral Form - https://shorturl.at/fHSW9
Fertility Clinic
• Dr M Atkinson
Use the above referral form
Uro-Gynaecology Clinic - Gynaecologist:
• Dr L Bates – Use the above referral form
See Western Sydney HealthPathways Adult Continence Assessment - Specialist continence clinics - Westmead Uro-
Gynaecology - Pelvic Floor Unit for more referral details https://westernsydney.communityhealthpathways.org/12396.htm
Vulva Clinic - Gynaecologist
• Dr J Bradford – Use the above referral form
See Western Sydney HealthPathways Sexual Health Assessment - University of Western Sydney Vulvo-Vaginal Clinic for more
referral details https://westernsydney.communityhealthpathways.org/108275.htm
PATIENT WILL RECEIVE AN APPOINTMENT LETTER FROM HOSPITAL WITH THE DATE & TIME OF THEIR APPOINTMENT
Please contact the relevant hospital for enquiries regarding your appointment.
Westmead: Fax to 8890 5198 or Email: [email protected]
Blacktown: HealthLink eReferral only. For further details, visit:
https://www.wslhd.health.nsw.gov.au/information-for-health-care-professionals/ereferals
Blacktown only contact (Gynae Nurse 0437174682 or 8670 8356)
Auburn: Fax to 8759 3246 or Email: WSLHD-Auburn-Women’[email protected]
V13 12/01/2024

Gynaecology Clinic Referral Form V13

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Gynaecology Clinic Referral Form V13

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GYNAECOLOGY CLINIC REFERRAL LETTER

CIRCLE PERSONAL DETAILS:

Phone: _________ Fax:_ Provider No: ________

GP signature: _____ Date: _

SPECIALITY GYNAECOLOGY CLINIC INFORMATION

General Gynaecology Clinic - Gynaecologists:

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