Surname:	<PtSurname>
	Firstname:	<PtFirstName>
	DOB:	<PtDoB>	
Referral From	
Doctor Name:	<DrName>
Provider Number:	<DrProviderNo>
Phone:	<UsrPhone>	Fax: <UsrFax>
Address:	<Practice>
	<UsrAddress>

Patient Details	
	
First Name(s):	<PtFirstName>
Family Name:	<PtSurname>
Preferred Name:	<Preferred Name>
Title:	<PtTitle>	
Birth Date:	<PtDoB>

Address: <PtAddress>
	Mailing Address (if different): 
<PtPOAddress>	
Tephone No: <PtPhoneH>
Home:	<PtPhoneH>
Mobile:	<PtPhoneMob>	
Work:<PtPhoneWk>	

Procedure	
Termination of pregnancy:	<Termination of pregnancy:>	
Contraception:	<Contraception>	
Vasectomy:	<Vasectomy:>	

Type of Termination of Pregnancy
(If applicable) 

Surgical Termination:	<Surgical Termination>
Medical Termination in Clinic: 	<Medical Termination in Clinic  >
Medical Termination using Tele-abortion:	<Medical Termination Using Tele-abortion>
Date of Last Menstrual Period: 	<Date of Last Menstrual Period>

Type of Contraception
(If applicable) 

Contraceptive Injection:  	<Contraceptive Injection>	  
Contraceptive Implant:  	<Contraceptive Implant>
Copper IUD:	                                <Copper IUD>
Hormonal IUS:                                    <Hormonal IUS>

Tele-abortion (Only fill in if the patient is being referred to this particular service )
	
Instead of attending a Marie Stopes clinic in person, your patient will have her medical abortion consultation at home. She will connect via a phone call to a Marie Stopes doctor in another location who will conduct the consultation in accordance with the law in your patient’s state. Marie Stopes will have access to free decision-based counselling beforehand if needed. After the consultation, Marie Stopes  will send the medications via registered courier. Your patient will take the medications at home with a support person and as directed by the doctor. She will have access to our free 24-hour telephone nurse aftercare number. We will conduct a follow-up assessment and may engage your support if and when necessary.	

Eligibility Criteria	
Location:
(Lives in VIC, NSW, QLD, TAS,NT or WA)	<PtState>	
Access to 24-hour emergency medical care within 2 hour of home	<Access to 24-hour emergency medical care within 2>	
Less than 8 weeks gestation:	<Less than 8 weeks gestation>	
16 years or older:	<PtAge>	
Medicare eligible:	<PtMCNo>	
Speaks and understands English:	<Speaks and understands English>	
Access to the internet, telephone, computer/laptop/tablet:	<Access to the internet, telephone, computer/laptop>	

Ultrasound	
Pregnancy has been confirmed through ultrasound
(Fax ultrasound report to 03 9658 7440)	<Pregnancy has been confirmed through ultrasound>	
Name of imaging service	<Imaging Service Name>	
Ultrasound date	<Ultrasound Date>	

Baseline serum beta HCG	
Pathology Provider
(Indicate on the pathology request that a copy needs to be marked ‘urgent’ and faxed to 03 9658 7440)	<Pathology Provider for Serum Beta HCG>	

Patient’s Blood Group		
Bloodgroup	<Blood Group>	
Pathology provider for bloodgroup/RBC antibodies
(If bloodgroup unknown. Indicate on the pathology request that a copy needs to be marked ‘urgent’ and faxed to 03 9658 7440)	<Ix>