Open access endoscopy e-referral Please fill in the below fields to create a referral request for your patient for an open access endoscopy. We will contact your patient shortly. Referral forGastroscopyColonoscopy HospitalsCampsie Day Surgery, CampsieLakeview Private Hospital, Baulkham HillsNorwest Private Hospital, Bella VistaSydney Adventist Hospital, WahroongaSomerset Private Hospital, Kingswood Co-morbidities Medications IndicationsAbdominal painRefluxDysphagiaWeight lossPositive FOBTPolyp surveillancePR bleedingChange in bowel habitsConstipationDiarrhoeaWeight lossFamily history of oesophageal cancerFamily history of gastric cancerFamily history of bowel cancer Referring Doctor Details:- Referring doctor name Provider number Contact number Referral date (if not today) Patient Details:- SalutationMrMrsMsMasterMissOther Name Date of birth Contact number Medicare number Does patient have private healthYesNoUnsure Private health fund and membership number Additional notes
