Sunshine Coast Hospital & Health Service (SCHHS) Central Intake 
GASTROENTEROLOGY OPEN ACCESS ENDOSCOPY REFERRAL FORM

Secure electronic transfer to: (NQ45600007J)
Specialty referred to: Endoscopy
(Alternatively this referral can be faxed to the Central Booking Office on Fax: 07 5202 0555)

Open Access Endoscopy Request

Specialist - <Specialist referred to?>	  

(Affix patient label here)	
Referring Doctor details	Patient details	
Referring doctor: <DrName>
Date of referral: <TodaysDate>
Practice address: <UsrAddress>
Contact details - Phone: <UsrPhone>
                            Fax: <UsrFax>	Re: <PtFirstName> <PtSurname>
Address: <PtAddress>
Phone - Home: <PtPhoneH>
Mobile: <PtPhoneMob>
DOB: <PtDoB>
Sex: <PtSex>	
UPPER GI ENDOSCOPY <Request Upper GI Endoscopy?>	

Indications (select all that apply):
<Upper GI endoscopy indications (select all that apply)>

Other indication:
<Other upper endoscopy indication (please specify)>

Date of last upper GI endoscopy: <Date of last upper GI endoscopy, if known>
	
COLONOSCOPY <Request Colonoscopy?>	

Indications (select all that apply):
<Colonoscopy indication (select all that apply)>

Other indication:
<Other colonoscopy indication (please specifiy)>

Date of last colonoscopy: <Date of last colonoscopy, if known>
	
REQUIRED INFORMATION	

Relevant history and examination:
<Relevant history and examination>

Essential investigations (please attach) <Essential investigations: FBC, ELFT, Iron studies,>:
FBC 
ELFT
Iron Studies

iFOBT (if under NBCSP): <Attach iFOBT report if under NBCSP>

Previous endoscopy reports and histology (please attach): <Please attach any available endoscopy reports and histology>

Details of any anticoagulation (select all that apply):
<Details of any anticoagulation>
 
Diabetes history, (tick if relevant):
Diabetes on oral hypoglycaemics <Diabetes on oral hypoglycaemics?>
Diabetes on insulin <Diabetes on insulin?>

Any other relevant past medical history (GI surgery, cardiac or lung disease):
<Any other relevant PMH (GI surgery, cardiac or lung disease)?>

 	
This referral is for an Open Access Endoscopy only.
A Gastroenterology Outpatient review will only be organised if clinically necessary	
Please refer to Health Pathways for referral advice and encourage the patient to complete the patient health questionnaire. For further information contact Endoscopy Unit Ph. 5202 2222. 	

SCHHS-funded care at a private facility
If deemed medically appropriate, treatment and care for patients on a Sunshine Coast Hospital and Health Service theatre waiting list may be transferred to a private hospital and will require release, use and disclosure of personal and health information by Sunshine Coast Hospital and Health Service and the facility to which care is transferred (in accordance with the Privacy Act).
If the patient does NOT consent to care at another facility please tick box <Patient does NOT consent to go to SCUPH for public endoscopy>
	
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			

If unable to send electronically, fax to (07) 5202 0555

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