ENDOSCOPY SERVICES 
REFERRAL FORM	Dalley Street
LISMORE  NSW  2480
Telephone: 02 6627 9266
Facsimile: 02 6627 9268	
 PATIENT DETAILS	
Surname <<Patient Demographics:Surname>>
Given Names <<Patient Demographics:First Name>>
Date of Birth <<Patient Demographics:DOB>>    Age <<Patient Demographics:Age>>
Phone Number (Home) <<Patient Demographics:Phone (Home)>> Phone Number (Work)  <<Patient Demographics:Phone (Work)>>  Phone Number (Mobile) <<Patient Demographics:Phone (Mobile)>>
Medicare Card No: <<Patient Demographics:Medicare Number>>   Expiry Date: <<Patient Demographics:Medicare Expiry Date>>	
 REQUEST	
 <<Select Request Type>>	
 PREFERRED GASTROENTEROLOGIST	
 <<Select Preferred Gastroenterologist>>	
 INDICATION	
 <<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	
 <<Clinical Details:Medication List>>	
 REFERRING DOCTOR	
 Print Name <<Doctor:Name>>                                        Signature
 Date <<Miscellaneous:Date>>                                         Provider No.  <<Doctor:Provider Number>>	

Patient Health Summary

Name: <<Patient Demographics:Full Name>>	Practice Details:
<<Practice:Name>>	
Address:  <<Patient Demographics:Full Address>>	<<Practice:Address>>	
D.O.B.:	<<Patient Demographics:DOB>>	<<Practice:Phone>>	
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)>>		

	

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>>