MRN	
SURNAME	

GIVEN NAME(S)	

DOB	
SEX	
AMO	
WARD/CLINIC	

	(Please enter information or affix Patient Information Label)	
Positive Faecal Occult Blood Test - Colonoscopy Referral Form	
Patient details	Referring Doctor details	
Name: <PtFullName>	Name: <RefName>	
Date of Birth: <PtDoB>	Date of Referral: <TodaysDate>	
1 Aboriginal  1 Torres Strait Islander	Provider No: <DrProviderNo>	
Address:<PtStreet>	Address: <DrStreet>	
Suburb: <PtCity>     Postcode: <PtPostcode>	Suburb: <DrCity>   Postcode: <DrPostcode>	
Email: <PtEmail>	Phone: <DrPhone>	
Phone:(h) <PtPhoneH>	Fax: <DrFax>	
Medicare No:<PtMCNo>	Email: <DrEmail>	
Gender: <PtSex>   Other: 	GP Signature:	
Weight (kg): 	Referral valid for: 1 12 months    1 Indefinite	
SVH MRN (if known):	Interpreter needed:  1 Yes 1 No  Language: <PtEthnicity>	
One Colonoscopist (Gastroenterologist or Surgeon*) must be selected	
 1 Dr D Williams	 1 Dr N De Luca	 1 Dr R Feller	
 1 Dr S Ghaly	 1 Dr M Danta	 1 Dr A Stoita	
 1 Dr A Kim	 1 Dr A Meagher*	 1 Dr R Gett*	
 1 Dr G Owen*	Are you happy for the patient to see the next available Endoscopist: 1 Yes   1 No	
Reason(s) for Referral	Medical History	
 1 FOBT +	 1 Heart disease:	
 1 NBCSP  1 Yes ID No:          (attach results)	 1 Coronary artery stents	 1 Heart failure	
 1 Date of last Colonoscopy: ...... / ....... / .........	 1 Pacemaker/defibrillator	 1 Angina	
	 1 Prosthetic valve	 1 Atrial Fibrillation	
 1 Allergies	 1 Diabetes    1 Type I    1 Type II	
 1 Smoker:	pack years	 1 Lung disease	
 1 ETOH	 1 Liver disease	
	 1 CVA / TIA	
  1 Attach blood test results 	 1 Malignancy	
	 1 Kidney disease   1 Creat............. 1eGFR ..............	
  1 Able to give informed cosent	 1 Mental health: ....................	
Medications	
 1 Insulin	 1 Warfarin	 1 Clopidogrel (Plavix)	
 1 Xarelto	 1 Eliquis	 1 Pradaxa	
 1 Steroids	 1 Immunosuppression	 1 SGLT2 inhibitors	
 1 Other:	
Comments	
	
Please fax to (02) 8382 3983. Incomplete referrals will be returned. Email: SVHS.Gastro@svha.org.au Phone: 8382 2061