02 4910 0591reception@beechnutmedical.com
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Beechnut Medical · Gastroenterology

Endoscopy Referral

Gastroscopy & colonoscopy referrals. Please complete all relevant fields — the clinical detail below helps us triage urgency and plan safe sedation and bowel preparation.

For use by medical practitioners only · 55 Lindsay St, Hamilton NSW 2303 · (02) 4910 0591

1 Patient Details

2 Referring Doctor Details

3 Reason for Referral & Procedure

e.g. iron-deficiency anaemia for investigation, altered bowel habit, surveillance, dyspepsia not responding to PPI, positive FOBT.
Please select at least one procedure.
e.g. significant weight loss, PR bleeding, anaemia, dysphagia, abnormal imaging.

4 Medication Safety

These medications affect bleeding risk and peri-procedural fasting. Please tick all that apply — our team will provide tailored withhold instructions.

Note: aspirin can nearly always be continued.

5 Clinical Information

Include risk factors: family history of GI malignancy, alcohol, smoking, IBD, Barrett's oesophagus, DVT in last year, previous malignancy.
e.g. OSA, significant cardiac/respiratory disease, prior anaesthetic complication, BMI > 40.

By submitting, you confirm the patient is aware of this referral. Information is handled in accordance with the Privacy Act 1988 and stored securely by Beechnut Medical.

Please complete the required fields highlighted above.

Referral received

Thank you. Your endoscopy referral has been submitted to Beechnut Medical. Our team will be in contact to arrange the procedure. For urgent matters please call (02) 4910 0591.

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