Date: <TodaysDate>	
Patient Name: Re: <PtName>	
Address:  <PtAddress>	
Home Number: <PtPhoneH>	
Mobile Number:<PtPhoneMob>	
Date of Birth: <PtDoB>	
Request for: <Request for>	
Reason for Colonoscopy: <Reason for Colonoscopy>	
If other, please specify: 	
Reason for Upper Endoscopy: <Reason for Upper Endoscopy>	
If other, please specify: 	
Allergies: <Reactions>	
Patient BMI > 40?: <Does the patient have a BMI over 40?>	
Blood thinners: <Blood thinners>	
Diabetic Status: <Diabetic Status>	
Current Medications: 
<SelectedRx>	
Current History:
<SelectedPMH>	
Referring Dr: <DrName>	
Provider Number: <DrProviderNo>	
Address:  <DrAddress>	
Phone:  <DrPhone>        Fax: <DrFax>	

Signature_______________________________________________

Date: <TodaysDate>
	
NOTE TO PATIENT:

This referral is for a Direct Access Service, which means you will not require an initial consultation with the specialist Gastroenterologist. You will be given intravenous sedation and as such you should not drive, operate machinery or sign important documents for 24 hours following your procedure. You must have a responsible adult to collect you from the Day Surgery Unit, accompany you home and stay with you the night following your procedure.                                                                                                                                 If polyps are removed at colonoscopy, you must not undertake domestic travel for 72 hours and international travel for 3 weeks. Patients need to return to their referring doctor for results and follow-up care unless otherwise indicated.