Hospital use only:
Clinic triage category: ¨ Urgent ¨ 6 weeks ¨ 12 weeks ¨ Routine
¨ Incomplete referral – return to GP
Comments:
Name of triaging Doctor:
HOSPITAL USE ONLY
Name:
Date of Birth:
Gender:
UR Number:
OR affix patient label
*Please review the SVHM Endscopy Pathways and other clinical information before making a referral to SVHM Endoscopy services
Endoscopy referral
for Gastroenterology, Colorectal and Upper GI Surgery Clinics *
*Please review the St Vincent’s Endoscopy pathway and Pre-Referral Guidelines before making your referral at
https://svhm.org.au/home/health-professionals/specialist-clinics/e/endoscopy/referral-information-for-doctors
Patient details Referring doctor details
St Vincent's UR (if known): St Vincent's UR
Name: Patient Demographics.Full Name Name: Patient Demographics.Full Name
Date of Birth: Patient Demographics.DOB Practice: Practice.Name
Sex: Patient Demographics.Gender
Address: Patient Demographics.Full Address Practice Address: Practice.Address
Phone (Home): Patient Demographics.Phone (Home) Phone (Work): Patient Demographics.Phone (Work) Phone: Practice.Phone Fax: Practice.Fax
Mobile: Patient Demographics.Phone (Mobile) Provider number: Treating Doctor.Provider Number
Medicare number: Patient Demographics.Medicare Number Date: Miscellaneous.Date
Pension card number: Patient Demographics.Pension Number Email: Treating Doctor.E-mail
DVA number: Patient Demographics.DVA Number
Aboriginal or Torres Strait Islander origin? (Y/N) ATSI Origin Clinic requested: Clinic requested
Interpreter required? (Y/N) Interpreter required
Language: Language-interpreter
Type of patient (please mark "x" in the relevant box below)
q National Bowel Cancer Screening Patients
Please attach NBCS form and NBCS patient ID and fax to 9231 3489 NO FURTHER INFORMATION REQUIRED
q Endoscopic recall / surveillance patients
Please attach past endoscopy reports (with histology if available)
Complete the check-box section below and fax to 9231 3489
q New Patient referral (Mark selection with "X")
Upper GI symptoms present q Lower GI symptoms present q
Please complete remainder of form below and fax to 9231 3489
Complete for Recall and New Patients ONLY
REASON(S) FOR REFERRAL
Upper GI
Symptoms present for : Upper GI
q Bleeding
q Haematemesis
q Melaena
q Iron deficiency anaemia (attach FBE / Fe studies)
q Unintentional weight loss: kg
q Dysphagia/pain on swallowing
q Persistent nausea or vomiting
q Loss of appetite
q Epigastric pain
q Reflux
q Atypical chest pain
q Abnormal imaging (attach report)
q Other, please state:
Lower GI
Symptoms present for : Lower GI
q PR bleeding
q Positive FOBT
q Blood in stools à qBright qDark / mixed
q Iron Deficiency Anaemia (attach FBE / Fe studies)
q Change in bowel habit (constipation/loose stools)
q Unintentional weight loss: kg
q Rectal or abdominal mass
q Abdominal pain
q Abnormal imaging (attach report)
q Known large polyp requiring removal
(attach colonoscopy and path reports)
q Surveillance
q Previous Ca bowel
q Previous polyps (attach histology of previous polyps)
q Family history of colorectal cancer
q Anal pain
q Other, please state:
Additional clinical information to assist with determining urgency of referral or procedure
Please fax referral to (03) 9228 3489. Incomplete referrals will be returned!
For any booking/referral enquiries phone (03) 9231 2898.
Medication
Clinical Details.Medications - Current Regular
Past History
Clinical Details.Past History
Investigations
Clinical Details.Result List (Selected)
Referring Doctor: Treating Doctor.Name
Signature: Date: Miscellaneous.Date
Referral Valid for: Referral Valid for
Prompt to complete