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: <<Patient Demographics:Full Name>>	Name: <<Doctor:Name>>	
Date of Birth: <<Patient Demographics:DOB>>	Date of Referral: <<Miscellaneous:Date (short)>>	
Aboriginality: <<Patient Demographics:ATSI>>	Provider No: <<Doctor:Provider Number>>	
Address:<<Patient Demographics:Address>>	Address: <<Doctor:Address>>	
Suburb: <<Patient Demographics:City>>      Postcode: <<Patient Demographics:Postcode>>	Suburb: <<Doctor:City>>      Postcode: <<Doctor:Postcode>>	
Email: <<Patient Demographics:E-mail>>	Phone: <<Doctor:Phone>>	
Phone:(h) <<Patient Demographics:Phone (Home)>>   	Fax: <<Doctor:Fax>>	
Medicare No:	Email: <<Doctor:E-mail>>	
Gender: <<Patient Demographics:Gender>>   Other: 	GP Signature:	
Weight (kg): 	Referral valid for: 1 12 months    1 Indefinite	
SVH MRN (if known):	Interpreter needed:  1 Yes  1 No   
Language: <<Patient Demographics:Language Spoken>>	
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 +      Date of test: ...... / ....... / .........	 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.................	
 1 Able to give informed consent	 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