Montserrat Day Hospitals
Adult Open Access Endoscopy Referral
Brisbane Gastroscopy & Colonoscopy & The Digestive Health Clinics
Ph: (07) 3833 6701 Fax: (07)3833 6740
Indooroopilly – North Lakes – Samford Road
(Also serving Ipswich, Longreach & Emerald)

Date: 
To: Montserrat Central Referrals (CM40000007H)

Patient Details:
RE:
DOB: 
Address: 

Phone:
Home:		Mobile: 
Sex:		Age: 

Referring General Practitioner:
Doctors Name
Practice Name
Practice Address
Phone: 
Fax: 
Email: 
Provider Number: 

Reason for Referral: 
Urgency: 	 If Urgent Why: 

Request for Colonoscopy:
Other Reason: 

Request for Gastroscopy: 
Other Reason: 

Past Medical History:
Current Medications:
 (Please include specifically if patient is on: Insulin, Warfarin, Clopidogrel, Iscover, Plavix, Pradaxa or Aspirin)

Diabetic Status: 
Allergies: 
BMI: 

Signature: __________________________________________________

Note: Colonoscopy Patients will need to attend an in-person preparation appointment at least 3 days before the procedure. Patients can not drive on the day of their procedure and must be accompanied by an adult family member or friend.

DVA Number: 
Insurance:
Medicare Number: