Med Centre Name~
Doctors Name~

Date ~

Flinders Fertility Fax 8155 5330
To Dr ~
Flinders Fertility
24 Gordon St
Glenelg  SA  5045
enquire@flindersfertility.com.au

Dear Doctor~
			
Re:  *Patients Name~
DOB ~ 
Address~
Medicare No.~ 
Phone Number~ 	and her/his partner	*~ Partners Name~ 
DOB ~ 
Address~
Medicare No.~ 
Phone Number~ 	

Presenting Problem:

Thank you for seeing Patient Name~ and Partner Name~

Past History:

BMI or Height & Weight:

Allergies:

Relevant Investigations 

Any available infertility investigations / Any recent infection screens  

Current Medications:

CST Results:  (please attach current CST result)

Yours sincerely

Dr Field~
Provider No.~