DIRECT ACCESS ENDOSCOPY REQUEST

Procedure
(please type ‘x’ in appropriate box/s)
	Colonoscopy		Gastroscopy		Colonoscopy/Gastroscopy	

Proceduralist
	Dr K C Yee		Dr Ben McCulloch		Next available	

Patient Details
Name	<<Patient Demographics:Full Name>>	
Address	<<Patient Demographics:Address Preferred>>  <<Patient Demographics:Address Preferred City>>  <<Patient Demographics:Address Preferred Postcode>>	
Ph (hm)	<<Patient Demographics:Phone (Home)>>	Ph (mob)	<<Patient Demographics:Phone (Mobile)>>	DOB	<<Patient Demographics:DOB>>	

Clinical Indication  
	National Bowel Cancer Screening Program							
											
	FOB Positive 			Constipation 			Anaemia/Iron Deficiency 			Reflux	
											
	Previous Polyps 			Diarrhoea 			Loss of Weight 			Dysphagia	
											
	Family History 			PR bleeding 			Abdominal Pain 			Barrett’s	
											
	Other (please indicate)		

Diabetic			Yes			No		Warfarin			Yes			No	
															
Insulin			Yes			No		Xarelto			Yes			No	
															
Lap Band			Yes 			No		Pradaxa			Yes			No	
															
Clopidogrel			Yes			No		Eliquis			Yes			No 	

Referring Doctor
Name	<<Doctor:Name>>	Provider No.	<<Doctor:Provider Number>>	
Practice name	<<Practice:Name>>	Address	<<Practice:Address>>	
Phone	<<Practice:Phone>>	Fax	<<Practice:Fax>>	
Signature		Date	<<Miscellaneous:Date>>	

Medical History
<<Clinical Details:History List>>

Allergies
<<Clinical Details:Allergies/Adverse Reactions>>