THE ROYAL HOSPITAL FOR WOMEN
GYNAECOLOGY OUTPATIENTS DEPARTMENT REFERRAL FORM
GPs to return by FAX on 02 9382 6246 
                                     All referrals are triaged prior to appointment details being sent directly to the	            patient within 10 working days from receiving this referral form.

ÿ Colposcopy		ÿ Pap smear abnormality	ÿ Abnormal Bleeding		ÿ Reproductive Endocrine
Dr Leo Leader		Prof William Ledger		Prof William Ledger		Dr Michael Costello
Dr Juman Farjo		Dr Sean Burnet		Dr Sean Burnet	
Dr Sean Burnet		Dr Juliette Koch			Dr Juliette Koch			ÿ Vulva Health
Dr Nadya Chami		Dr Jason Chow			Dr Jason Chow			Dr Yasmin Tan
			Dr Nadya Chami			Dr Nadya Chami
	Dr Juman Farjo

ÿ Menopause		ÿ Endo-Gynaecology		ÿ Chronic Pelvic Pain		ÿ Uro-Gynaecology
Dr Sheila O’Neal		Prof Abbott			Prof Theirry Vancaillie		Prof Kate Moore
Dr Terri Foran		Dr Haryun Won			Dr Jason Chow
Dr Juliette Koch		Dr David Rosen	

ÿ Contraception	 ÿ Pelvic Floor			ÿ Paediatric & Adolescent Gynaecology
Dr Terri Foran	   	 Dr Krishnan			Dr Rebecca Deans
		   	 Dr Juman Farjo

Reasons for Referral & Investigation
Please provide significant symptoms, signs, investigation results and any reasons that identity a need for early hospital assessment. If there is insufficient information, triaging will be delayed.
________________________________________________________________________________________________________________________________________________________________

Investigations ordered: (please attach all relevant results to assist us to triage correctly)
Pathologyÿ	Ultrasoundÿ	Other Imagingÿ    Details:______________________________________
_______________________________________________Other:____________________________

Does the patient have any Special Needs i.e. Obesity or wheelchair… Details:__________________________________________________________________________

PATIENT DETAILS
Surname: <PtSurname>	First Name: <PtFirstName>
DOB: <PtDoB>         Contact number:<PtPhoneMob>       Medicare number:<PtMCNo>
Address: <PtStreet>, <PtCity>,<PtPostcode>
Country of Birth: <PtCountry of Birth> Interpreter Required ÿYes – Language_____________________

REFERRING DOCTORS DETAILS/STAMP:
Name: <DrName>        Provider Number: <DrProviderNo>
Practice address: <DrAddress>