AFFIX PATIENT LABEL HERE

SHPH 102A – OPEN ACCESS ENDOSCOPY REFERRAL FORM

Patient Details:
Name: 	
DOB: 	
Ph/Mobile: 	

For any enquiries, please contact us on 02 4862 9400 or
please email this referral form together with GP referral letter to: SHPAdmit@ramsayhealth.com.au
Referral to:
•	A/Prof Ahmad Alrubaie	q Dr Nicolas De Luca	q Dr Joon Kim
•	Dr Cameron Bell	q Dr Serena Singh	q A/Prof Michaella Smith
•	Dr Farzan Bahin	q Dr Stephen Williams	q Open / Next available

Request for:
•	Gastroscopy – Indications provide details below
Bleeding
•	Haematemesis
•	Melaena
•	Iron deficiency anaemia (attach FBC / Fe studies)
Other
•	Heartburn / Reflux
•	Unintentional weight loss
•	Dysphagia
•	Persistent nausea or vomiting
•	Loss of appetite
•	Epigastric pain
•	Abnormal imaging (attach report)
•	Dysplasia screening – Barrett’s Oesophagus
•	Other (details below)

•	Colonoscopy – Indications provide details below
Bleeding
•	Positive FOBT è	q NBCSP q Other
•	PR bleeding	è	q Bright q Dark / mixed
•	Iron deficiency anaemia (attach FBC / Fe studies)
Other
•	Previous history of polyps
•	Change in bowel habit (constipation or loose stools)
•	Unintentional weight loss
•	Rectal or abdominal mass
•	Abdominal pain
•	Abnormal imaging (attach report)
•	Family History of polyps or colorectal cancer
•	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.

Referring Doctor Name	Signature	Date
*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 month
•	

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.