LNDMF0054 Rev Mar 22	

ENDOSCOPY SERVICES
REFERRAL FORM	

                            Dalley Street
                      LISMORE NSW 2480
                 Telephone: 02 6627 9266
                   Facsimile: 02 6627 9268

PATIENT DETAILS	

Surname:
Given Names:
Date of Birth: <<Patient Demographics:DOB>>
Phone (Home): <<Patient Demographics:Phone (Home)>>	
<<Patient Demographics:Surname>>
<<Patient Demographics:First Name>>
Age: <<Patient Demographics:Age>>             Phone (Mob): <<Patient Demographics:Phone (Mobile)>>
Phone (Work): <<Patient Demographics:Phone (Work)>>	

PAST MEDICAL HISTORY AND CURRENT MEDICATIONS	

•	Please attach a current health summary and 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)	

Age > 80	
	
Diabetic	

BMI > 40	
X	
Severe Asthma / CAL	

CVA / TIA within 3 months	
	
Takes Anitplatelets / NOAC's	

Acutely ill / febrile	
	
Unstable Angina	

Chronic Renal Failure	
	
Intending overseas travel within 2 weeks	

Cardiac / vascular stents within last 12 months	
	
Confusion / Dementia	

AMI within 3 months	

REQUEST	

Upper Gastrointestinal Endoscopy	
	
Colonoscopy	

PREFERRED GASTROENTEROLOGIST	

Dr M Cornwell	
	
Dr H Hope	
	
Dr I Singh-Grewal	

Dr D Whitaker	
	
Dr A Thomson	
	
OR first available	

INDICATION (Symptoms, signs, and/or investigation findings prompting referral) - Select all that apply	

Positive FOB	
	
National Bowel Cancer Screening Program	
	
Palpable mass - Rectal	

Anaemia	
	
Rectal bleeding, duration __ weeks	
	
Family History	

Fe deficiency	
	
Diarrhoea (stool culture negative), duration __ weeks	
	
Past polyps	

Palpable mass - Abdominal	
	
Unexplained abdominal pain > 6 weeks	
	
Past cancer	

Reflux	
	
Dysphagia	
	
Unexplained weight loss	

Other	

Date of last colonoscopy: <<Date of last colonoscopy if not done at St Vincents>>                                     (Provide a copy of results if not performed at St Vincent's)	

REFERRING DOCTOR	

Print Name: <<Doctor:Name>>
Date: <<Miscellaneous:Date>>
Referring Practice: 
<<Practice/Location:Location Name>>
<<Practice/Location:Address>>
<<Practice/Location:Phone>>	
Signature: 
Provider No. <<Doctor:Provider Number>>	

	

	

Patient Health Summary
Name: <<Patient Demographics:Full Name>>
Address: <<Patient Demographics:Full Address>>
D.O.B.: <<Patient Demographics:DOB>>
Medicare No.: <<Patient Demographics:Medicare Number>>
Medicare Card Expiry: <<Patient Demographics:Medicare Expiry Date>>
Home Phone: <<Patient Demographics:Phone (Home)>>
Work Phone: <<Patient Demographics:Phone (Work)>>
Mobile Phone: <<Patient Demographics:Phone (Mobile)>>

Printed on: <<Miscellaneous:Date (long)>>	<<Practice/Location:Location Name>>
<<Practice/Location:Address>>
<<Practice/Location:Phone>>	
_________________________________________________________________________________________________

Family History
<<Clinical Details:Family History>>

Social History
<<Clinical Details:Social History>>

Past Medical History
<<Clinical Details:History List>>
Allergies
<<Clinical Details:Allergies/Adverse Reactions>>
Immunisations
<<Clinical Details:Immunisation List>>