Download Medical Director Referral Template

For all appointments call
1300 4 GASTRO
(1300 4 42787)
www.gastros.com.au
Chermside Day Hospital
Chermside Medical Complex
Level 1, 956 Gympie Rd
Chermside Q 4032
PH: 07 3120 3407
FX: 07 3120 3443
Brisbane Endoscopy Services
Suite 16-18, McCullough Centre
259 McCullough St
Sunnybank Q 4109
PH: 07 3344 1844
FX: 07 3344 2739
NorthWest Private
Hospital
Endoscopy Unit
137 Flockton St
Everton Park Q 4053
PH: 07 3353 3322
FX: 07 3353 9325
Dr Roderick Roberts MB BS FRACP
Dr William Robinson MB BS FRACP
Dr Neville Sandford MB BS FRACP
Dr Michael Miros MB BS FRACP
Dr Andrew Bryant MB BS FRACP
Dr Hugh Spalding MB BS FRACP
Wesley Hospital
3rd Floor, Day Centre
451 Coronation Drive
Auchenflower Q 4066
PH: 07 3870 3799
FX: 07 3870 5069
Date: <<Miscellaneous:Date (short)>>
Patient Name: Re: <<Patient Demographics:Full Name>>
Address: <<Patient Demographics:Full Address>>
Home Number: <<Patient Demographics:Phone (Home)>>
Mobile Number:<<Patient Demographics:Phone (Mobile)>>
Date of Birth (Patients between 16 to 84 years accepted): <<Patient Demographics:DOB>>
Request for: <<Request for>>
Reason for Colonoscopy: <<Reason for Colonoscopy>>
If other, please specify:
Reason for Upper Endoscopy: <<Reason for Upper Endoscopy>>
If other, please specify:
Allergies: <<Clinical Details:Allergies>>
Patient BMI > 40?: <<Does the patient have a BMI over 40?>>
Blood thinners: <<Blood thinners>>
Diabetic Status: <<Diabetic Status>>
Current Medications:
<<Clinical Details:Medication List>>
Current History:
<<Clinical Details:History List>>
Referring Dr: <<Doctor:Name>>
Provider Number: <<Doctor:Provider Number>>
Address: <<Doctor:Full Address>>
Phone: <<Doctor:Phone>>
Fax: <<Doctor:Fax>>
Signature_______________________________________________
Date: <<Miscellaneous:Date (short)>>
PATIENT INFORMATION:
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This referral is a request for an Open Access service which means you will not require an initial consultation with the specialist
gastroenterologist.
An Upper Endoscopy (looking down the throat into your stomach) requires a single appointment for the procedure. A Colonoscopy
(looking at the bowel) requires two appointments. The first is to see the specially trained Registered Nurse who will discuss your medical
history, low fibre diet and how to take the preparation medication. The second appointment is for your colonoscopy procedure.
When phoning to make your booking, please have on hand your Medicare card, Private Health Fund details, pension card and letter of
referral.
Patients with a BMI (Body Mass Index) >35 may be preferentially booked into the Wesley or North West Hospitals for patient’s safety.
Patients with a BMI >40 will be assessed by the prep nurse and may require a consultation.
For patients booked for colonoscopy, you are advised to have someone stay with you while taking the bowel preparation.
Patients will be given intravenous sedation for endoscopic procedures. It is illegal for you to drive on the day of your procedure; you must
not operate machinery or sign important documents for 12 hours; and you must have a responsible adult to accompany you home and
care for you 12 hours after the procedure.
If you have had polyps removed, you must not undertake domestic travel for 48 hours and international or remote travel for two weeks
after your procedure.
Patient must return to their referring doctor for results and follow-up care.
Version: 2.0 MD 160614