Date: Miscellaneous.Date	
Patient Name: Re: Patient Demographics.Full Name	
Address:  Patient Demographics.Full Address	
Home Number: Patient Demographics.Phone (Home)	
Mobile Number: Patient Demographics.Phone (Mobile)	
Date of Birth: Patient Demographics.DOB	
Request for: Request for	
Reason for Colonoscopy: Reason for Colonosco	
If other, please specify: 	
Reason for Upper Endoscopy: Reason for Upper End	
If other, please specify: 	
Allergies: Clinical Details.Allergies	
Patient BMI > 40?: Does the patient hav	
Blood thinners: Blood thinners	
Diabetic Status: Diabetic Status	
Current Medications: 
Clinical Details.Medication List	
Current History:
Clinical Details.History List	
Referring Dr: Treating Doctor.Name	
Provider Number:  	
Address:  Treating Doctor.Full Address	
Phone:  Practice.Phone       Fax: Practice.Fax	

Signature_______________________________________________

Date: Miscellaneous.Date
	
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.