Dr Rebecca Ryan
BMBS (Hons), FRACP

Patient’s Name:___<PtFullName>______ D.O.B: ____<PtDoB>_

Contact Number:   __(HP)<PtPhoneH>______(MOB)  <PtPhoneMob>  

Address:  _<PtAddress>_
	
Appointment type:
	[ <Consultation> ] Consultation
	[  <Telehealth>] Telehealth
	[ <Gastroscopy> ] Gastroscopy
	[ <Colonoscopy> ] Colonoscopy
	
Colonoscopy patients will need to sit a compulsory appointment at least 4 days prior to their procedure to collect the preparation solution and instructions
	
Clinical Notes: <Clinical Notes>

	
Is patient on: [ <Warfarin> ] Warfarin [ <Plavix> ] Plavix  [ <Xarelto> ] Xarelto
[ <Clopidogrel> ] Clopidogrel
[ <Is patient a diabetic (type & controlled by):> ] Is patient a diabetic (type & controlled by): 	Patient BMI:
<Patient BMI:>	

	

Referring

Doctor’s Details: <DrDetails>

Provider Number: <DrProviderNo>

Signature: ____________________________
	
Date: _<FormattedDate>_____________

	
Phone: 07 3833 6701 GP Hotline: 07 3833 6788
Fax: 07 3833 6740 Email: bookings@montserrat.com.au
Electronic Referrals can be sent via Medical Objects to provider number: CM40 0000 07H
	
  [ <Robina Private Hospital> ] Robina Private Hospital 
Procedural Open Access
1 Bayberry Lane
Robina, Q 4224	  [ <John Flynn Private Hospital> ] John Flynn Private Hospital
Consulting Suite
Suite 2B Medical Centre
42 Inland Drive, Tugun, Q 4224	

Location

	

Robina Private Hospital
1 Bayberry Lane,
Robina, Q 4224

	

John Flynn Private Hospital
Suite 2B Medical Centre
42 Inland Drive, Tugun, Q 4224

	

Phone:07 3833 6710 	Fax: 07 3833 6740
To re-order forms call 07 3833 6740