LNDMF0054 Rev March 22		

	

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>	

Phone (Mob): <PtPhoneMob>
Phone (Work):  <PtPhoneWk>	

PAST MEDICAL HISTORY and CURRENT MEDICATIONS			
•	Please attach a current health summary and any relevant pathology with this referral			
Patients with any of the following indicators may not be suitable for open access and will be reviewed 
for suitability by a Gastroenterologist (please tick all that apply) <Please tick all indicators that apply from the list below:>			
<Age > 80> Age > 80
<BMI > 40> BMI > 40
<CVA/TIA within 3 months> CVA/TIA within 3 months
<Acutely ill / febrile> Acutely ill / febrile	
<Chronic Renal Failure> Chronic Renal Failure
<Cardiac/vascular stents within the last 12 months> Cardiac/vascular stents within the last 12 months
<AMI within 3 months> AMI within 3 months	<Diabetic> Diabetic
<Severe Asthma / CAL> Severe Asthma / CAL
<Takes antiplatelets/NOAC's> Takes antiplatelets/NOAC's 
<Unstable angina> Unstable angina
<Intending overseas travel within 2 weeks> Intending overseas travel within 2 weeks
<Confusion / Dementia> Confusion / Dementia		
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: Symptoms, signs, and/or investigation findings prompting referral			
<Indication: Symptoms, signs, and/or investigation findings prompting referral - select all that apply>
			
REFERRING DOCTOR			
Print Name: <UsrName>		Signature: 	
Date: <TodaysDate>		Provider No.: <DrProviderNo>
Referring Practice: <Practice>			

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>