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ENDOSCOPY SERVICES 
REFERRAL FORM	Dalley Street
LISMORE  NSW  2480
Telephone: 02 6627 9266
Facsimile: 02 6627 9268		
PATIENT DETAILS			
Surname: <PtSurname>   
Given Names: <PtFirstName>    
Date of Birth:  <PtDoB>  Age: <PtAge>
Phone (Home): <PtPhoneH>	
Medicare # <PtMCNo> <PtMCLine>
Medicare Expiry: <PtMCExpiry>
Phone (Mob): <PtPhoneMob>
Phone (Work):  <PtPhoneWk>	

REQUEST <Select Request Type:>			
 <Upper Gastrointestinal Endoscopy> Upper Gastrointestinal Endoscopy  <Colonoscopy> Colonoscopy			
PREFERRED GASTROENTEROLOGIST <Select preferred gatroenterologist from list below:>			
<Dr M Cornwell> Dr M Cornwell	<Dr H Hope> Dr H Hope	<Dr I Singh-Grewal> Dr I Singh-Grewal
<Dr D Whitaker> Dr D Whitaker	<Dr A Thomson>Dr A Thomson	<OR first available> or first available			
INDICATION 		(PLEASE PROVIDE A PATIENT HEALTH SUMMARY WITH THIS REFERRAL)			
<Indication>			
Patients with any of the following indicators will not be suitable for open access and will require at least
a telephone consultation with a Gastroenterologist:			
•	Age > 80
•	BMI > 40
•	CVA within 3 months
•	Acutely ill / febrile	
•	AMI within 3 months
•	Chronic Renal Failure
•	Patients who have had drug eluting stents within the last 18 months	•	Diabetic
•	Severe Asthma / CAL
•	TIA within 3 months
•	Takes anticoagulants
•	Takes clopidogrel
•	Unstable angina
•	Intending overseas travel within 2 weeks
•	Confusion / Dementia		
CURRENT MEDICATIONS			
<SelectedRx>			
REFERRING DOCTOR			
Print Name: <UsrName>		Signature: 	
Date: <TodaysDate>		Provider No.: <DrProviderNo>				

Patient Health Summary
Name: <PtFormalName>	<Practice>	
Address: <PtAddress>	<UsrAddress>	
D.O.B.:	<PtDoB>	<UsrPhone>	
Medicare No.:   <PtMCNo> <PtMCLine>
Medicare Card Expiry: <PtMCExpiry>		
Home Phone: <PtPhoneH>
Work Phone: <PtPhoneWk>  
Mobile Phone: <PtPhoneMob>		

Printed on <FormattedDate>

Family History

<FamilyHx>
Social History
<SocialHx>
Past Medical History
<SelectedPMH>
Allergies
<Reactions>
Immunisations
<Imm>