Patient Details 
Name:	<PtPrefName> <PtSurname>	DOB:	<PtDoB>	
Medicare / legal name:	<PtFullName>	Gender identity/ pronouns:	<GenderIdentity>/ <GenderIdentity><Pronouns>	
Email:	<PtEmail>	Phone: 	<PtPhoneMob>	

PLEASE TICK: 

I confirm that my patient:

<I confirm my patient is: already on oestrogen> is already on oestrogen
<I confirm my patient is: on a stable or max. does of current oestrogen AND> is on a stable or maximum dose of current oestrogen 

AND 

<does not wish to take a daily medication/ prefers convinence of implants, OR> does not wish to take a daily medication / prefers the convenience of implants, OR
<does not tolerate other forms of oestrogen, OR> does not tolerate other forms of oestrogen OR
<is unable to achieve therapeutic oestrogen leves (oestrogen < 25nmol/l, poor clinical response or ongoing virulisation), AND> is unable to achieve therapeutic oestrogen levels (oestrogen < 250 nmol/L, poor clinical response or ongoing virulisation)

AND 

<can tolerate a minor medical procedure under local anaesthetic that causes a small scar> can tolerate a minor medical procedure under local anaesthetic that causes a small scar  

Ongoing care 

<Ongoing care: I am referring for implant insertion only and I can continue gender affirming hormonal care OR> I referring for the purposes of oestrogen implant insertion only, OR
<Ongoing care: I am referred for all gender affirming hormonal care needs, I will continue as their primary care provider for other health care needs> I am referring for all gender affirming hormonal care needs, I will continue as their primary care provide for other health care needs 	

Clinical Details & Examination 

Past medical history <SelectedPMH>
Medications <SelectedRx>
Allergies/ adverse reactions <Reactions>
BP 
<Recent BP (& date):>

BMI 
<BMI (only if patient consents/ leave blank if declines or not suitable for them):>

Oestrogen history  
Current oestrogen type & dose:	<Current oestrogen (formulation & dose):>	
Most recent oestrogen level:	<Most recent oestrogen level (nmol/L):>	
Most recent testosterone level:	<Most recent testosterone levels (nmol/L):>	
Reason for change to implant:	<Reason for change to implant:>	

Referring GP & contact details
<DrName>
<DrQualifications>
<DrAddress>
Phone: <DrPhone> Fax: <DrFax>

	GP stamp

	

INVESTIGATIONS 
Please include recent FBC, EUC, LFTs, oestrogen & testosterone levels (where possible but RCC can arrange)
<Please also include recent FBC, EUC, LFTs, oestrogen and testosterone results (where possible but RCC can arrange if not available at time of appointment)>
<Ix>