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	

	Endoscopy referral 
for Gastroenterology, Colorectal and Upper GI Surgery Clinics*	

*Please review the SVHM Endscopy Pathways and other clinical information before making a referral to SVHM Endoscopy services
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 (if known)>>		
Name:	<<Patient Demographics:Full Name>>	Name:	<<Doctor:Name>>	
Date of Birth:	<<Patient Demographics:DOB>>	Practice:	<<Practice:Name>>	
Sex:	<<Patient Demographics:Sex>>		
Address: 	<<Patient Demographics: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:  <<Doctor:Provider Number>>	
Medicare number: 	<<Patient Demographics:Medicare Number>>	Date: 	<<Miscellaneous:Date (short)>>	
Pension card number: 	<<Patient Demographics:Pension Number>>	Email: 	<<Doctor:E-mail>>	
DVA number: 	<<Patient Demographics:DVA Number>>		
Aboriginal or Torres Strait Islander origin? (Y/N)  <<Aboriginal or Torres Strait Islander origin>>	Clinic Selected: <<Clinic Selected>>	
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 Endoscopic Recall and New Patients ONLY	
REASON(S) FOR REFERRAL	
Upper GI 

Symptoms present for : <<Upper GI - Symptoms present for>>
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 - Symptoms present for>>
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: 	
Please fax referral to (03) 9231 3489. Incomplete referrals will be returned!
For any booking/referral enquiries phone (03) 9231 2898.	

Please attach medication, past medical history, and relevant pathology and imaging results with this referral	
Additional clinical information to assist with determining urgency of procedure:

	
Medication
<<Clinical Details:Medication List>>
	
Past History
<<Clinical Details:History List>>
	
Investigations
<<Summary:Investigation Results (Selected)>>

Referring Doctor:	<DrName>	
Signature:		Date: <<Miscellaneous:Date (short)>>
	
Referral Valid for	<<Referral Valid for:>>	
<<Click “Insert” & complete “Type of Patient” sect. etc>>