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Referral
This form is for use by medical practitioners only.
Patient Details
Name
*
Date of Birth
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Sex
M
F
O
Address
Street Address
Suburb
Postcode
Phone (h)
Phone (w)
Mobile
Medicare Number
Referring Doctor Details
Name
*
Practice
Address
Street Address
Suburb
Postcode
Phone (h)
Fax
Email address
*
Provider number
Interpreter
Is an interpreter required?
Y
N
Language
Request for endoscopy:
Gastroscopy
Colonoscopy
Gastroscopy
Bleeding
Haematemesis
Melaena
Iron deficiency anaemia (attach FBE/FE studies)
FBE/Fe studies
Drop files here or
Select files
Max. file size: 128 MB.
Suspected Malignancy
Unintentional weight loss
Dysphagia
Persistent nausea or vomiting
Loss of appetite
Epigastric pain
Abnormal imaging (attach report)
Other
Please note other suspected malignancy
Abnormal imaging report
Drop files here or
Select files
Max. file size: 128 MB.
Gastroscopy
Bleeding
Positive FOBT
Blood in stools
Iron deficiency Anemia (attach FBE/Fe studies)
Positive FOBT
NBCSP
Other
Blood in stools
Bright
Dark
Mixed
FBE/Fe studies
Max. file size: 128 MB.
Suspected Malignancy
Change in bowel habit (constipation or loose stools)
Unintentional weight loss
Rectal or abdominal mass
Abdominal pain
Abnormal imaging (attach report)
Known large polyp requiring removal (attach colonoscopy and path reports
Other
Please note other suspected malignancy
Abnormal imaging report
Drop files here or
Select files
Max. file size: 128 MB.
Colonoscopy and path reports
Drop files here or
Select files
Max. file size: 128 MB.
Additional clinical information to assist with determining urgency of the procedure
Please include details about risk factors (family history of gastro-intestinal malignancy, personal history of alcohol excess or smoking), relevant personal past medical history (e.g. Barrett's oesophagus, inflammatory bowel disease, DVT in last year, previous malignancy).
Anti-Coagulation / Anti-Platelet Therapy
None
Clopidogrel
Warfarin
Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
Prasugrel (Effient)
Ticagrelor (Brilinta)
* Aspirin can nearly always be continued
Can it be stopped? Comments
Current Medications
Relevant Past Medical History
Allergies
Has the patient had a previous colonoscopy?
No
Yes
Date of previous colonoscopy
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Attach colonoscopy report and pathology report
Drop files here or
Select files
Max. file size: 128 MB.
Has the patient had a previous gastroscopy?
No
Yes
Date of previous gastroscopy
Day
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Year
2025
2024
2023
2022
2021
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2019
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2015
2014
2013
2012
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2006
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1999
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1995
1994
1993
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1991
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1989
1988
1987
1986
1985
1984
1983
1982
1981
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1979
1978
1977
1976
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1972
1971
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1969
1968
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Attach colonoscopy report and pathology report
Drop files here or
Select files
Max. file size: 128 MB.
Does this patient have an increased risk for sedation or anaesthetic?
No
Yes
Comments
What is the patient's body mass index (bmi)?
Does this patient suffer from constipation?
This will help determine the appropriate bowel preparation
No
Yes
Comments
Deal with practitioner
Dr Kate Napthali
Dr Robert Foster
First available
Do you consider this urgent?
No
Yes
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