Open Access Endoscopy Request

(Affix patient label here)	
Referring Doctor details	Patient details	
Referring doctor: Treating Doctor.Name
Date of referral:Miscellaneous.Date
Practice address: Practice.Address
Contact details - Phone: Practice.Phone
                            Fax: Practice.Fax	Re: Patient Demographics.First Name Patient Demographics.Surname
Address: Patient Demographics.Full Address
Phone - Home: Patient Demographics.NOK Home Phone
Mobile: Patient Demographics.NOK Mobile Phone
DOB: Patient Demographics.DOB
Sex: Patient Demographics.Gender	
URGENT GASTROSCOPY REQUEST URGENT GASTROSCOPYCat 4 (Urgent)                                      GASTROSCOPY	
Confirmed iron deficiency anaemia IRON DEFICIENCY
>New onset dyspepsia >55 New dyspepsia >55
Upper GI Bleeding Upper GI Bleeding
Dysphagia Dysphagia
Melaena/Haematemesis Melaena/Haematemesis	Other: Other

Haemoglobin  Haemaglobin g/L
Ferritin  Ferritin ug/L
	
NON-URGENT GASTROSCOPY REQUEST NON-URGENT GASTROSCCat 5 (Non-Urgent)                             GASTROSCOPY	
Confirmed Barrett's Oesophagus Barrett's Oesophagus
Oesophageal reflux despite medical management Oesophageal reflux	Dyspepsia despite medical management Dyspepsia
Other: Other
Last endoscopy*: Last endoscopy	
URGENT COLONOSCOPY REQUEST URGENT COLONOSCOPY   Cat 4 (Urgent) COLONOSCOPY	
Confirmed iron deficiency anaemia Confirmed anaemia
Rectal BleedingRectal Bleeding
Change in bowel habit >45Bowel habit changes	Positive FOBT Positive FOBT
Details: Details
Other: Other	
NON-URGENT COLONOSCOPY REQUEST  NON-URGENT COLONO Cat 5 (Non-urgent)                              COLONOSCOPY	
 Previous polyps Previous polyps
Polyp histology*: Polyp histology *
Previous Colorectal Cancer (CRC ) CRC 
CRC Operative details*: CRC Operative detail
Family history CRC Family history CRC
Details*: Details	Other:  Oher
Date of last colonoscopy*: last colonoscopy	
Additional Clinical details including co-morbidities and relevant medications	
 Renal Disease Renal Disease       Diabetes Diabetes
Additional Clinical details (GI surgery; cardiac and respiratory disease etc) Extra Clinical info	Aspirin Aspirin
Warfarin Warfarin
NOAC NOAC 
Clopidogrel or Ticagrelor Clopidogrel or Ticag
Insulin Insulin
Oral Hypoglycaemics Oral hypoglycaemics	
This referral is for an Open Access Endoscopy only.
A Gastroenterology Outpatient review will only be organised if clinically necessary	
* Denotes essential information. Please refer to Health Pathways https://sunshinecoast.healthpathwayscommunity.org/LoginFiles/Logon.aspx?ReturnUrl=%2f  for referral advice and encourage the patient to complete the patient health questionaire. For further information contact Endoscopy Unit Ph. 5202 2222. 	
Departmental use only	
Triage Category	c 4	c 5	Timeframe:		
Outpatient Clinic	c GI	c Hep	Category:		
Suitable	c SCUH	c NGH	c GH	c SCUPH	
Endoscopy Clinic review	c None	c Nurse phone clinic			

Secure electronic transfer to: (NQ45600007J)
If unable to send electronically, fax to (07) 5202 0555
Specialty referred to: Endoscopy

Investigations: Clinical Details.Result List (Selected)