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Are you a patient or health professional?*

Patient
Health Professional

Are you having your baby at Royal Brisbane and Women's Hospital?*

Yes
No

Unfortunately, this service is only available to women who are having their baby at the Royal Brisbane and Women's Hospital.

Health professional Information

Will your patient deliver their baby at Royal Brisbane and Women's Hospital?*

Yes
No

Unfortunately, this service is only available to women who are having their baby at the Royal Brisbane and Women's Hospital.

Has your patient consented to this program referral?*

Yes
No

Your patient must consent before completing a referral on their behalf

Referrer name

First Last

Designation*

Referrer contact number*

Pregnancy Information

Maternity care*

GP shared care
Tertiary care
Midwifery Group Practice (Ngarrama, Aurora, Aster)
RBWH Midwives - (Pegasus, Phoenix)
RBWH Community Midwives - (Nundah)
Birth Centre Midwives
Private Practice Obstetrician
Unsure
Private Practice Midwives

View more information about which maternity care option suits you.

Pre-pregnancy weight (kg)*

Pre-pregnancy height (cm)*

Pre-pregnancy BMI (kg/m2)

If your BMI is less than 25kg/m2 and you're unsure if you're gaining weight faster than recommended, use the pregnancy weight gain chart (BMI is less than 25kg/m2) to track your weight progression.

How many weeks are you currently pregnant?*

How many weeks is your patient currently pregnant?*

Current weight*

Patient Information

Name*

First Name Last Name

Date of birth*

Address*

Street Address Suburb State Post code

Email*

Mobile*

Preferred contact number for appointment (if different from above)

Do you need an interpreter?*

No
Yes

Does your patient need an interpreter?*

No
Yes

If you require an interpreter, this service will be provided to you in-person at the hospital. List your preferred language and we will organise an interpreter for you.

Language

Appointment details

Preferred days to receive calls*

We have two coaches who work two days each with variable hours to offer flexibility. Please choose one of the following options that will best suit you ongoing:

Coach one: Monday 10-6pm and Thursday 7.30-3.30pm
Coach two: Tuesday 9.30am-6pm and Friday 7.30-3.30pm

Preferred days to receive calls*

We have two coaches who work two days each with variable hours to offer flexibility. Please choose one of the following options that will best suit your patient ongoing:

Coach one: Monday 10-6pm and Thursday 7.30-3.30pm
Coach two: Tuesday 9.30am-6pm and Friday 7.30-3.30pm

Preferred time to receive calls (tick all that apply)*

Calls are approximately 30 minutes. Please note, not all times are available on all days.

Information disclaimer and consent

While Queensland Health endeavours to ensure that the online transmission of the form, containing your information, over the internet is secure, the inherent nature of the internet means that there is a potential risk that your information may be viewed or intercepted by third parties.

Accordingly, submission through the online form shall be at your own risk and Queensland Health accepts no responsibility or liability for any unauthorised access to your information contained in the form when it is submitted online over the internet.

It is inadvisable to complete this form on a public or shared computer. If a public or shared computer is used then this shall be at your own risk, and you must take all reasonable steps to ensure your confidential information does not remain on the computer or in any way accessible by a third party.

Individuals who submit the form online should receive an acknowledgement from Queensland Health that the Form has been sent, on the screen, following submission. Queensland Health accepts no responsibility or liability if this acknowledgement does not appear or we do not receive your online submission.

You acknowledge that you have read and understood the Queensland Health’s Privacy Statement and Disclaimer.

I hereby accept and agree to abide by, the above terms and conditions for submitting this Form.*

I accept and agree

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