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: <<Miscellaneous:Date (long)>>
To: Monsterrat Central Referrals

Patient Details:
<<Patient Demographics:Full Name>>
<<Patient Demographics:Full Address>>
DOB: <<Patient Demographics:DOB (long)>>
Phone: <<Patient Demographics:Phone (Home)>> <<Patient Demographics:Phone (Mobile)>>
Sex: <<Patient Demographics:Sex>>

Referring General Practitioner:
<<Doctor:Name>>
<<Doctor:Full Address>>
Provider Number:<<Doctor:Provider Number>>

Phone: <<Doctor:Phone>>
Fax: <<Doctor:Fax>>
Email: <<Doctor:E-mail>>

Request for Colonoscopy: <<Colonoscopy request>>
Reason for Colonoscopy: <<Colonoscopy reason>>
Other reason: <<Colonoscopy other reason>>

Requesy for Gastroscopy: <<Gastroscopy request>>
Reason for Gastroscopy: <<Gastroscopy reason>>
Other reason: <<Gastroscopy other reason>>

Urgency: <<Urgency>>
If Urgent Why?: <<If Urgent Why>>

Past Medical History:
<<Clinical Details:History List>>

Current Medications:
<<Clinical Details:Medication List>>

(Please include specifically if patient is on: Insulin, Warfarin, Clopidogrel, Iscover,, Plavix, Pradaxa Aspirin)

Diabetic Status: <<Diabetic status>>
Allergies: <<Clinical Details:Allergies>>
BMI if known: <<BMI>>

Signature: _________________________________________________________

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

DVA Number: <<Patient Demographics:DVA Number>>
Medicare Number: <<Patient Demographics:Medicare Number>>