Flemington Road & Grattan St Parkville VIC 3052	PELVIC PAIN SERVICE REFERRAL
•	To ensure the accurate categorisation of your patient’s referral, please provide as much information as possible 
•	Please include recent blood results, pelvic ultrasound and any other relevant information 	
Referral to Frances Perry House Pelvic Pain Service through Gynaecare Victoria®	
Please e-mail, fax or mail referrals to:
E-Mail: pps.frp@ramsayhealth.com.au
Fax number: 03 9348 2633
Mail: Level 2, Suite 2, 20 Flemington Road, Parkville, VIC 3052
Phone: 03 9348 2833	
Patient Details	
Family Name: 	Given Name: 	
Date of birth: 	
Address:                                                                                                               	
                                                                      	Postcode: 	
Postal Address (If different from above):	
                                                                                                  	Postcode: 	
Phone (H):	Phone (W): 	Phone (M):	
Medicare Number:	Medicare Card Expiry: 	
Private Health Insurance: 	
Private Health Insurance Member Number: 	
Private Health Insurance Reference Number: 	
Referring Medical Officer Details 	
Family Name: 	Given Name: 	
Provider Number:  	
Address:                                                                                                               	
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Postal Address (If different from above):	
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Phone: 	Fax: 	
E-Mail: 	
Nominated General Practitioner Details (If not referring Medical Officer) 	
Family Name: 	Given Name: 	
Provider Number: 	
Address:                                                                                                               	
                                                                                                                 Postcode:	
Postal Address (If different from above):	
                                                                                                                               Postcode: 	
Phone: 	Fax: 	
E-Mail: 
	
Reason for Referral 	

	
	
Assessment of Pelvic Pain	
Is it cyclical pelvic pain? 	YES                           NO 	
Is it constant pelvic pain? 	YES                           NO 	
How long has the pain been present? 		
What analgesia is the patient taking? 	
	
If opioid use, how much and how long? 	
	
Has a pelvic ultrasound been performed?
If yes, please attach report 	YES                           NO 	
Other reasons for referral? 		
	
Relevant Medical and Surgical History  	

	

	
Current Medications (Include description, dosage, rate and frequency) 	

		

		
Allergies/Adverse Drug Reactions 	

		

Referring Practitioner 	
Name:                                                  

Signature:                                         

Date: