Gynaecological Oncology
Chris O’Brien Lifehouse
PO Box M33
Missenden Road
NSW 2050
Email: clinics@lh.org.au
Fax: +61 2 9383 1031
Ph: +61 2 8514 0262

Referral to Gynaecological Oncology at Lifehouse
Patient Details
Surname	<<Patient Demographics:Surname>>	
Given Names	<<Patient Demographics:First Name>>, <<Patient Demographics:Middle Name>>	
Gender	<<Patient Demographics:Gender>>	
Date of Birth	<<Patient Demographics:DOB>>	
Address	<<Patient Demographics:Address>>
	
Contact Phone Number	Home:<<Patient Demographics:Phone (Home)>>	Work:<<Patient Demographics:Phone (Work)>>	Mobile:<<Patient Demographics:Phone (Mobile)>>	

Referral Details
Referral to:	Please choose from the table below	

A/Prof T. Tejada, A/Prof S. Saidi, A/Prof S. Pather, Prof J. Carter, Dr R.Farrell, Dr R.Sayer	
Rapid Access Hysteryscopy clinic – A/Prof Sam Saidi	
GTD clinic (molar pregnancy) – S. Philip NP, T. Tejada	
Named referral only	

Period of Referral	3 months/12 Months/Indefinite	
Interpreter Required	YES/NO
Language:	
Reason for Referral	Colposcopy/Suspected Gynaecological Cancer/GTD
Other:	
Relevant Past Medical History	
	
Medications	Medications List attached: YES/NO
<<Clinical Details:Medication List>>
	
Allergies	<<Clinical Details:Allergies/Adverse Reactions>>
	
Investigations / Test Results included	Pathology: YES/NO
Histopathology: YES/NO	Radiology: YES/NO
Other:	
Additional Information		

Referrer’s Name: <<Doctor:Name>>			Contact Number: <<Doctor:Phone>>
Provider Number: <<Doctor:Provider Number>>	Date: <<Miscellaneous:Date>>

LLIFEHOUSE GYNAECOLOGIC ONCOLOGY: GUIDELINES FOR REFERRAL
Colposcopy referrals include any of the following:	
Abnormal pap smear (according to national guidelines)	Please provide a copy of the referral smear	
Vulval, cervical or vaginal lesion or vaginal bleeding suspicious for malignancy	Please provide a copy of the last smear result if
known	

Suspected Gynaecological Cancer referrals include any of the following:	
Ultrasound or CT suggestive of gynaecological
malignancy:
 Complex pelvic mass (non-simple cyst)
 Thickened endometrium (>4mm if
postmenopausal)
 Ascites
 Any other imaging raising suspicion for
gynaecological cancer	Please request a Ca125 if not already
Performed

Please provide a copy of the imaging
report(s)	
Postmenopausal bleeding (normal vaginal examination)	Please request an urgent transvaginal ultrasound (or see below)	

Rapid Access Hysteroscopy referrals include any of the following:	
 Postmenopausal bleeding
 Unexpected bleeding on HRT or tamoxifen
 Intermenstrual bleeding over 45 and endometrium unusually thickened on ultrasound	Please indicate if an ultrasound has
been performed or requested. If not it
will be arranged on the day of the
appointment.	

GTD (gestational trophoblastic disease) referrals include any of the following:	
Recent diagnosis of molar pregnancy (partial mole, complete mole or choriocarcinoma) or follow-up of diagnosed molar pregnancy	Please provide a copy of the pathology
report	

Contact Numbers	
Referral Fax Number	(02) 9383 1031	
Secretary	(02) 8514 0262	
Direct contact numbers for clinical queries:
Dr Sam Saidi (02) 85140258
Dr Trevor Tejada-Berges (02) 85140592
Dr Selvan Pather (02) 85140257
Prof Jonathan Carter, Dr Rhonda Farrell and Dr Robyn Sayer (02) 85140262