THS North West
Public Direct Access Endoscopy Service	
Referred to:	 Referring General Practitioner:	
	NWAHS Public Direct Access Endoscopy Service
Mersey Community Hospital
Bass Highway
Latrobe TAS 7307
Phone: 6478 5390   Fax:  6441 5942
Email: daes@ths.tas.gov.au	<DrName>
<Practice>
<DrAddress>
Phone: <DrPhone>  Fax: <DrFax> 
Email: <DrEmail>
Provider No.: <DrProviderNo>

Referral Date:    <TodaysDate>	

Patient Details:		
Name:	<PtFirstName> <PtSurname>
Date of Birth:	<PtDoB>
Contact Address:	<PtStreet>
	<PtCity>  <PtState>    <PtPostcode>
Phone:	<PtPhoneH>
Work:	<PtPhoneWk>
Mobile:	<PtPhoneMob>	Pension Card Number: <PtPensionNo>
Medicare Number: <PtMCNo>
DVA Number: <PtDVANo>
IHI Number: <PtIHI>  
Insurance: <Does the Patient have Insurance>
Emergency Contact:
Name:  <Emergency Contact Name>
Phone:  <Emergency Contact Phone>

Patient's Usual GP:  <DrName>	

If the Patient needs to be seen by a consultant before an Endoscopy, then: 
1) They are not appropriate for the Direct Access Endoscopy Service.
 2) A referral should be sent to the Outpatient Department at Burnie or Mersey.

		 <PtTitle> <PtSurname> does not need to be seen by a consultant before endoscopy.	

Service Requested:		
1st Scope required	<1st Scope Required>	
Clinical reason for referral	<Clinical reason for referral for 1st scope>	
2nd Scope (if required)	<2nd Scope (If required)>	
Clinical reason for referral	<Clinical reason for referral for 2nd scope>	
Urgency:	<Urgency and Reason for Urgency>	
Previous FOBT done:	<Previous FOBT Done?>	
    If Yes, the result was:	<If Yes, the result was>	
    Was this from the National Bowel Cancer Screening Program?	<    Was this from the National Bowel Cancer Screen>	
Does the Patient have diabetes?	<Does the patient have diabetes?>	
Is the Patient on Warfarin or Clopidogrel?	<Is the Patient on Warfarin or Clopidogrel?>	
Is the Patient frail, and lives alone?	<Is the Patient frail, and lives alone?>	
Are there any cardiovascular or renal impairments?	<Are there any cardiovascular or renal impairments?>	
Is there any GIT Specific Gamily History.	<GIT specific family history>	

		<PtTitle>  <PtSurname> 	
		is aware that he/she will be managed by the next available consultant within this service.   <PtFirstName> and I understand we will be notified when this referral has been categorised and placed on the waiting list and  also when being discharged from the service.	

Please include all relevant clinical information and previous endoscopies to allow for accurate triage.

Clinical Information:		
  <PtFirstName> <PtSurname> DOB:  <PtDoB>

   Progress Notes: 
  <Visits>

  Warnings: <Comment>

  Allergies:  <Reactions>

  Current Medication:
  <SelectedRx>

  Family History: 
  <FamilyHx>
 
  Past Medical History:
  <SelectedPMH>

 ---------------------------------------------------------------------------------------------------------------------------------

  Investigation Results:
  <Ix>

 I understand if this referral contains insufficient information it will be returned to me for clarification.

 Yours sincerely,

 <DrName>   
Signature:......................................................Date: <TodaysDate>