RAPID ACCESS CLINIC 
UROLOGY CLINIC
Referral Form
Private Patients and DVA Gold Card Holders
Call 8275 3364 for an appointment.
Please bring this referral form with you, or your GP can fax it to 8275 3334.

SPECIALISTS
	Dr Michael Chong		Dr Jason Lee	
	Dr Mark Siddins			

PATIENT DETAILS 
Patient Name: [Full Name]						Sex:  M  /   F
Address: [Address]
Postal Address (if different to above): [Postal Address]
DOB: DD/MM/YYYY		Phone: [Phone]			Mobile: [Mobile]
Private Health Insurance:  Y  /  N	Fund Name/Number: [Fund Name/Number]		
DVA Gold Card Holder:  Y  /  N		Card/Fund Number: [Card/Fund Number] 

CLINICAL DETAILS

1. Macro Haematuria
	Contrast CT	
	EUC/CBP/INR (if app)	
	PSA	
	UMCS	

2. Retention
*Please attach relevant results and a Patient Health Summary

	Creatinine/EUC	
	Renal Ultrasound	
	PSA	
	UMCS	

3. Suspected Malignancy
*Please ensure diagnostic test results accompany your patient to the appointment

Send patient with current imaging/test results	

4. Acute Renal Colic
	Spiral CT	
	Creatinine	
	Ca/Ph/Urate	
	UMCS	

REFERRING DOCTOR 
Referring Doctor’s Name: [Referring Doctor’s Name]
Provider Number: [Provider Number]
Address: [Doctor’s Address]
Phone: [Doctor’s Phone]			Fax: [Doctor’s Fax]
Signature:					Date: DD/MM/YYYY

NOTE: Patients who have been injured as a result of a motor vehicle accident, work related injury, public liability claim or are not registered with Medicare are not eligible for this service.

FLINDERS PRIVATE HOSPITAL
1 Flinders Drive Bedford Park SA 5042
8275 3333 - flindersprivatehospital.org.au