Patient details |
Referring doctor details |
St Vincent's UR (if known):
St Vincent's UR
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Name:
Patient Demographics.Full Name
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Name:
Patient Demographics.Full Name
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Date of Birth:
Patient Demographics.DOB
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Practice:
Practice.Name
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Sex:
Patient Demographics.Gender
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Address:
Patient Demographics.Full Address
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Practice Address:
Practice.Address
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Phone (Home):
Patient Demographics.Phone (Home)
Phone (Work):
Patient Demographics.Phone (Work)
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Phone:
Practice.Phone
Fax:
Practice.Fax
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Mobile:
Patient Demographics.Phone (Mobile)
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Provider number:
Treating Doctor.Provider Number
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Medicare number:
Patient Demographics.Medicare Number
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Date:
Miscellaneous.Date
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Pension card number:
Patient Demographics.Pension Number
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Email:
Treating Doctor.E-mail
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DVA number:
Patient Demographics.DVA Number
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Aboriginal or Torres Strait Islander origin? (Y/N)
ATSI Origin
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Clinic requested:
Clinic requested
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Interpreter required? (Y/N)
Interpreter required
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Language:
Language-interpreter
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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
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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
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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
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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:
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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:
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