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

Date: <<dates>>
To: Montserrat Central Referrals (CM40000007H)

Patient Details:
RE:<<patientfullname>>
DOB:                    Age: <<age>>	Sex: <<sex>>
Address: <<address1>>
<<address2>>
<<address>>
Phone:
<<phoneh>>
<<phonew>>
<<phonem>>

Referring General Practitioner:
Name: <<docname>>
Address: <<practicename>>
<<practiceaddr1>>
<<practiceaddr2>>
<<practiceaddr3>>
Phone: <<practicephone>>
Fax: <<practicefax>>
Email: <<docemail>>
Provider Number: <<docprov>>

Reason for Referral: 
Urgency: 		If Urgent Why: 

Request for Colonoscopy: 
Other Reason: 

Request for Gastroscopy: 
Other Reason: 

Past Medical History: 

Current Medications: <<printcurrentmedication>>
 (Please include specifically if patient is on: Insulin, Warfarin, Clopidogrel, Iscover, Plavix, Pradaxa or Aspirin)

Diabetic Status: 			Allergies: <<printallergies>>
BMI: (please indicate patient BMI)

Signature: __________________________________________________
		Dr Name:<<docname>>		Date:<<dates>>
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:  <<medicareno>>