Direct Access Endoscopy/Colonoscopy

Referral Form

Completed forms forwarded to Colorectal Specialist Group:
Email: admin@gisurgery.net.au 
Fax: 08-8275 3197	COLORECTAL SPECIALIST GROUP
Suite 209 Flinders Private Hospital,
Bedford Park, SA 5042 
Suite 6, 19 Alexander Ave,  
Ashford SA 5035 
Phone: 08-8371 3077  
Fax: 08-8275 3197	

PREFERRED SPECIALIST
(Patient will be booked onto the next available list; if ANY is ticked patient will be referred to earliest available list)
	Dr Dayan DeFontgalland		Dr Tiong Cheng (TC) Sia	
	Dr Eu Nice Neo		Dr Abdullah Rana	
	Dr Janina Kaczmarczyk		Any surgeon	

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] 

Medicare Number: [Card Number]

REQUESTED PROCEDURE
	Endoscopy	
	Colonoscopy	
	Endoscopy and Colonoscopy	

INDICATION
Asymptomatic patients with (please tick):
	Positive Faecal Occult Blood test		Previous history of polyps requiring surveillance	
	Family history of bowel cancer 		Iron deficiency anaemia (Endoscopy and colonoscopy)	

Clinical symptoms prompting colonoscopy, language barriers, consent difficulties and significant comorbidities will require initial specialist consultation prior to procedure. Direct access referrals can be independently discussed with our surgeons prior to procedure should the referring practitioner deem direct access appropriate.

PAST MEDICAL HISTORY
	YES	NO	DETAILS	
Cardiac				
Respiratory 				
Diabetes				
Renal impairment				
Cognitive status				
MRSA/VRE				
Other relevant				

MEDICATIONS
	YES	NO	DETAILS	
Warfarin				
Clopidogrel 				
Oral Anticoagulation				
Diabetic medication 				
Aspirin				
Iron				
Other relevant				

SLGT2 inhibitor agents include Dapagliflozin (Forxiga®), Empagliflozin (Jardiance®), Canagliflozin (Invokana® - available in New Zealand but not in Australia), or a combination with metformin (Xigduo®, Jardiamet®) are to be ceased 3 days prior

ALLERGIES

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