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:	<<Miscellaneous:Date>>	Indefinite referral:	<<Indefinite referral>>
If not indefinite, this referral is valid for 12 months.
PATIENT DETAILS
First name:	<<Patient Demographics:First Name>>	Surname:	<<Patient Demographics:Surname>>
Date of birth:	<<Patient Demographics:DOB>>	Age / Sex:	<<Patient Demographics:Age>>  <<Patient Demographics:Sex at Birth>>
Address:	<<Patient Demographics:Full Address>>
Home phone:	<<Patient Demographics:Phone (home)>>	Mobile:	<<Patient Demographics:Phone (mobile)>>
Medicare no.:	<<Patient Demographics:Medicare Number>>	Expiry:	<<Patient Demographics:Medicare Expiry Date>>
REQUEST
Colonoscopy:	<<Colonoscopy>>	Gastroscopy:	<<Gastroscopy>>	Consultation:	<<Consultation>>
REASON FOR REFERRAL
Symptoms:	<<Symptoms>>	Asymptomatic screening:	<<Asymptomatic screening>>
Positive FOBT / other test:	<<Positive FOBT or other test result>>	Follow up surveillance:	<<Follow up surveillance>>
Others:	<<Others>>
Clinical details / if Others, please specify:

CURRENT MEDICATIONS AND ALERTS
<<Clinical Details:Medication List>>
Allergies:	<<Clinical Details:Allergies/Adverse Reactions>>
Diabetes:	<<Diabetes>>	GLP-1 receptor agonist:	<<GLP-1 receptor agonist>>
SGLT2 inhibitors:	<<SGLT2 inhibitors>>	Renal impairment:	<<Renal impairment>>
Anticoagulants / antiplatelets (warfarin, Plavix, Xarelto, Eliquis, other):	<<Anticoagulants or antiplatelets>>
CLINICAL DETAILS
<<Clinical Details:History List>>
REFERRING DOCTOR
Name:	<<Doctor:Name>>	Provider no.:	<<Doctor:Provider Number>>
Practice:	<<Practice:Name>>
Address:	<<Practice:Address>>
Phone:	<<Practice:Phone>>	Fax:	<<Practice:Fax>>
Signature:	..............................	Date:	<<Miscellaneous:Date>>
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