If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

• Ectopic pregnancy
• Ruptured haemorrhagic ovarian cyst
• Ovarian torsion
• Acute/severe pelvic pain
• Significant or uncontrolled vaginal bleeding
• Severe infection
• Abscess intra pelvis or PID
• Bartholin's abscess / acute painful enlargement of a Bartholin's gland/cyst
• Acute trauma including vulva/vaginal lacerations, haematoma and/or penetrating injuries
• Post-operative complications within 6 weeks including wound infection, wound breakdown, vaginal bleeding/discharge, retained products of conception post-op, abdominal pain
• Urinary retention
• Acute urinary obstruction
• Any molar pregnancy
• Inevitable and / or incomplete miscarriage
• Hyperemesis gravidarum
• Ascites, secondary to known underlying gynaecological oncology

Reason for request

• To establish a diagnosis
• For treatment or intervention
• For advice and management
• For specialist to take over management
• Reassurance for GP/second opinion
• For a specified test/investigation the GP can't order, or the patient can't afford or access
• Reassurance for the patient/family
• For other reason (e.g. rapidly accelerating disease progression)
• Clinical judgement indicates a referral for specialist review is necessary

Relevant clinical information about the condition

• Presenting symptoms (evolution and duration)
• Physical findings
• Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
• All conservative options that have been pursued unsuccessfully prior to referral
• Body mass index (BMI)
• Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
• Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
• Current medications and dosages
• Drug allergies
• Alcohol, tobacco and other drugs use

Patient's Demographic Details

• Full name (including aliases)
• Date and country of birth
• Residential and postal address including whether patient resides at an aged care facility
• Telephone contact number/s – home, mobile and alternative
• Medicare number (where eligible)
• Name of the parent or caregiver (if appropriate)
• Name of delegate and contact details (Department of Corrective Services)
• Preferred language and interpreter requirements
• Identifies as Aboriginal and/or Torres Strait Islander
• Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

• Full name
• Full address
• Contact details – telephone, fax, email
• Provider number
• Date of referral
• Signature
• Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

Other relevant information

• Willingness to have surgery (where surgery is a likely intervention)
• Choice to be treated as a public or private patient
• Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)