Surname:	<<Patient Demographics:Surname>>
	Firstname:	<<Patient Demographics:First Name>>
	DOB:	<<Patient Demographics:DOB>>	
Referral From	

Doctors Name:           Treating Doctor.Name
Provider Number:	Treating 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.Mailing Address	
Telephone No:
Home:	Patient Demographics.Phone (Home)
Mobile:	Patient Demographics.Phone (Mobile)	
Work:Patient Demographics.Phone (Work)	

Procedure	
Termination of pregnancy:	Termination of pregn	
Contraception:	Contraception	
Vasectomy:	Vasectomy	

Type of Termination of Pregnancy
(If applicable) 

Surgical Termination:	Surgical Termination
Medical Termination in Clinic: 	Medical Termination 
Medical Termination using Tele-abortion:	Medical Termination 
Date of Last Menstrual Period: 	Date of Last Menstru

Type of Contraception
(If applicable) 

Contraceptive Injection:  	Contraceptive Inject	  
Contraceptive Implant:  	Contraceptive Implan
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 State	
Access to 24-hour emergency medical care within 2  hour of home	Access to 24-hour em	
Less than 8 weeks gestation:	Less than 8 weeks ge	
16 years or older:	Patient Demographics.Age	
Medicare eligible:	Patient Demographics.Medicare Number	
Speaks and understands English:	Speaks and understan	
Access to the internet, telephone, computer/laptop/tablet:	Access to the intern	

Ultrasound	
Pregnancy has been confirmed through ultrasound
(Fax ultrasound report to 03 9658 7440)	Pregnancy has been c	
Name of imaging service	Name of imaging serv	
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	

Patient’s Blood Group		
Bloodgroup	Clinical Details:B	
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)	Clinical Details.Result List (Selected)