BINDING MARGIN – DO NOT WRITE
FILE IN MEDICAL RECORD	For any enquiries, please contact us on 02 42862 9400 or please email this referral form together with GP referral letter to SHPAdmit@ramsayhealth.com.au  
This form can be downloaded at www.southernhighlandsprivate.com.au
			OPEN ACCESS ENDOSCOPY REFERRAL FORM	
	Referral to:
q A/Prof Ahmad Alrubaie	q Dr Nicolas De Luca	q Dr Joon Kim
q Dr Cameron Bell	q Dr Serena Singh	q A/Prof Michaella Smith
q Dr Farzan Bahin	q Dr Stephen Williams	q Open / Next available				
	Patient Details:
Name: <PtFullName>
Date of Birth: <PtDoB>	Ph / Mobile: <PtPhoneMob>	Referring Doctor Details:
Name: <DrDetails>
Provider number: <DrProviderNo>
Phone: <DrPhone>			
	q Self-Funded	q Insured – Health Fund name:	 Membership no.:					
	Request for endoscopy:				
	q Gastroscopy – Indications provide details below 
Bleeding 
q Haematemesis 
q Melaena 
q Iron deficiency anaemia (attach FBC / Fe studies) 
Other 
q Heartburn / Reflux 
q Unintentional weight loss 
q Dysphagia 
q Persistent nausea or vomiting 
q Loss of appetite 
q Epigastric pain 
q Abnormal imaging (attach report) 
q Dysplasia screening – Barrett’s Oesophagus 
q Other (details below)	q Colonoscopy – Indications provide details below 
Bleeding 
q Positive FOBT	à	q NBCSP 	q Other 
q PR bleeding  	à	q Bright 	q Dark / mixed 
q Iron deficiency anaemia (attach FBC / Fe studies) 
Other 
q Change in bowel habit (constipation or loose stools) 
q Unintentional weight loss 
q Rectal or abdominal mass 
q Abdominal pain 
q Abnormal imaging (attach report) 
q Family History of polyps or colorectal cancer
q Other (details below)			
	Comments:				
	I have explained to the patient/person legally responsible for the patient, the nature and effect of the above procedure(s) and possible complications. In my opinion he/she understands this explanation.

				              <TodaysDate>
	Referring Doctor Name	Signature	Date				

SHP  SharePoint				SHPH 102A	
	Patient conditions NOT suited for Open Access Endoscopy				
	•	Aged > 75
•	BMI >40
•	Use of Clopidogrel, Ticagretor (Brillinta) or Blood Thinners	•	Previous problem with anaesthetics
•	Type 1 diabetes 
•	Type 2 diabetes on insulin
•	Renal insufficiency 	•	Congestive cardiac failure
•	Advanced lung disease 
•	Acute cardiac history
•	Pacemaker within 12 months		
	In the presence of significant health concerns / comorbidities, patients should have a consultation prior to any endoscopic procedure; please do not refer such patients for open access endoscopy.