Surname:	<<Patient Demographics:Surname>>
	Firstname:	<<Patient Demographics:First Name>>
	DOB:	<<Patient Demographics:DOB>>	
Referral From	
Doctor Name:	<<Doctor:Name>>
Provider Number:	<<Doctor:Provider Number>>
Phone:	<<Practice:Phone>>	Fax: <<Practice:Fax>>
Address:	<<Practice:Name>>
	<<Practice:Address>>

Patient Details	
	
First Name(s):	<<Patient Demographics:First Name>>
Family Name:	<<Patient Demographics:Surname>>
Preferred Name:	<<Preferred Name>>
Title:	<<Patient Demographics:Title>>	
Birth Date:	<<Patient Demographics:DOB>>

Address: <<Patient Demographics:Full Address>>
	Mailing Address (if different): 
<<Patient Demographics:Full Address Postal>>	
Telephone No:
Home:	<<Patient Demographics:Phone (Home)>>
Mobile:	<<Patient Demographics:Phone (Mobile)>>	
Work:<<Patient Demographics:Phone (Work)>>	

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)	<<Patient Demographics:State>>	
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:	<<Patient Demographics:Age>>	
Medicare eligible:	<<Patient Demographics:Medicare Number>>	
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	<<Clinical Details: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)	<<Summary:Investigation Results (Selected)>>