Epworth HealthCare
Endometriosis

Referral Form |
Are you a patient of an Epworth gynaecologist? | Yes | No
If not, are you willing to see an Epworth gynaecologist? | Yes | No

 	

 Patient details	

Name: |
UR (if an existing Epworth patient): | | | | |
Address: | | | | |
| | | Postcode: | |
Telephone: | | Email: | | |
Gender: | Pronouns | | DOB: | / | /
Medicare card number: | | Reference Number | | Expiry date: | /

Health fund:

Yes

No

Name of fund:

Membership number:

Department of Veteran Affairs:

Gold

White

Membership number:

 Next of kin details	
Name:

Telephone:	Relationship to patient:

 Referrer details	
Name:	Provider number:

Specialist

GP

Clinic name:

Patient’s usual GP (if not referrer):
Address:

Telephone:	Fax:
Email:

Postcode:

www.epworth.org.au/ juliaargyrouendocentre

Epworth HealthCare

Endometriosis
Referral Form

 Reason for referral	

Suspected endometriosis

Confirmed endometriosis

Pain

Fertility

Care coordination

Other

Additional information:

 History	

Is this patient already known to a gynaecologist?

Would they like to see the same specialist again?

Additional information:

 Medical information	
Imaging results:

Pelvic ultrasound:

MRI:

Other imaging (if performed):

Please attach any relevant correspondence, imaging, histology or pathology results with this referral. Details of relevant past medical history, current medications and allergies:

Other additional information:

Please email your referral form to our endometriosis nurse coordinator at EHendonurse@epworth.org.au

Julia Argyrou Endometriosis Centre at Epworth
Ground Floor, 185-187 Hoddle Street, Richmond VIC 3121 Phone 03 9516 2434 | Fax: 03 9429 4947
Email  EHEndocentre@epworth.org.au

www.epworth.org.au/ juliaargyrouendocentre

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