Title: Gastroenterology Referral Form
Author: Gastro Intestinal Specialists Brisbane

MBBS BMedSci FRACP FASGE FACG M.Phil (UQ)
Provider No. 264383UF
GASTROENTEROLOGY REFERRAL FORM
Date of referral:	<TodaysDate>	Referral valid for:	<Duration of referral>
PATIENT DETAILS
First name:	<PtFirstName>	Surname:	<PtSurname>
Date of birth:	<PtDoB>	Age / Sex:	<PtAge>  <PtSex>
Address:	<PtAddress>
Home phone:	<PtPhoneH>	Mobile:	<PtPhoneMob>
Medicare no.:	<PtMCNo>	Expiry:	<PtMCExpiry>
REQUEST
<Colonoscopy>  Colonoscopy	<Gastroscopy>  Gastroscopy	<Consultation>  Consultation
REASON FOR REFERRAL
<Symptoms>  Symptoms	<Asymptomatic screening>  Asymptomatic screening
<Positive FOBT or other test result>  Positive FOBT or other test result	<Follow up surveillance>  Follow up surveillance
<Others>  Others
Clinical details / if Others, please specify:
<Reason for referral>
CURRENT MEDICATIONS AND ALERTS
<SelectedRx>
Allergies:	<Reactions>
<Diabetes>  Diabetes - on tablets or insulin	<GLP-1 receptor agonist>  GLP-1 receptor agonist
<SGLT2 inhibitors>  SGLT2 inhibitors	<Renal impairment>  Renal impairment
<Anticoagulants or antiplatelets>  Anticoagulants / antiplatelets - warfarin, Plavix, Xarelto, Eliquis, other
CLINICAL DETAILS
<SelectedPMH>
REFERRING DOCTOR
Name:	<DrName>	Provider no.:	<DrProviderNo>
Practice:	<Practice>
Address:	<UsrAddress>
Phone:	<UsrPhone>	Fax:	<UsrFax>
Signature:	..............................	Date:	<TodaysDate>
Phone: 07 3193 0877     Fax: 07 3319 6466     reception@gisb.com.au     www.gisb.com.au
For all appointments please call: 07 3193 0877
St Andrew's War Memorial Hospital	Holy Spirit Northside Private Hospital
Sessional Suites, Level 4, Yellow lifts	Arnold Janssen Building, Suite 15, Level 1
457 Wickham Terrace, Brisbane QLD 4001	627 Rode Road, Chermside QLD 4032
Correspondence: PO Box 206, Ashgrove QLD 4060