Refer a patient Referring Doctor Doctor Phone Fax Provider Number Referral Date Patient Information TitleSelect...Mr.Mrs.Ms.Dr. First Name Last Name Email Address Fax Address History Weight Height Heart InformationCardiac StentsPacemakerImplantable defribulator MedicationsAnticoagulantsAntiplateletsInsulinOther Allergies Family History Reason Referral Previous Investigation Other Notes Referral Information Referral to specialistSelect Specialist...Dr. Helena ChoiDr. Henry CheungDr. Robert CheungDr. John Doe Referral to locationSelect Location...Castle HillGledswood HillBella Vista Referral UrgencySelect Urgency...ConsultUrgentNext Available Planned ProceduresSelect Procedure...GastroscopyColonoscopyHaemorrhoid Banding ColonoscopyPositive FOBT resultFamily history of CRCSurveillance for polypsUnexplained iron deficiency +/- anaemiaUnexplained progressive weight lossRectal bleedingBloody diarrhoea with negative stool MC&S Change in bowel habits >6 weeksUnexplained progressive weight lossAbdominal painPalpable mass (suggest consult)After first episode of proven diverticulitis to exclude neoplasm GastroscopyFamily history of stomach cancerUnexplained iron deficiency +/- anaemiaCoeliac disease screeningDyspepsia / RefluxDysphagia, odynophagiaUnexplained abdominal pain and weight lossPersistent vomiting and weight lossFor duodenal biopsy following positive serology in suspected coeliac diseaseScreening / surveillance of Barrett’s oesophagus and gastric intestinal metaplasi
