• The referral date and time.
  
• Name of the health facility you are sending the woman.
  
• Name, date of birth, ID number (if known) and address of the mother.
  
• Relevant health history and your findings on physical examination or lab test.
  
• Your suspected diagnosis.
  
• Any treatment you have given to the mother.
  
• Your reason for referring her.
  
• Your name, date and signature.