Endoscopy Referral

Use this form for colonoscopy, gastroscopy, surveillance, investigation of bowel symptoms, or endoscopic review.

Referrer details

Referrer name

Provider number

Practice / clinic

Best contact number

Referrer email

Patient details

Patient full name

Date of birth

Patient phone

Medicare / UR number

Requested procedure

Procedure requested

Urgency

Indication

Bowel cancer screening / surveillance Positive FOBT / FIT Rectal bleeding Iron deficiency anaemia Change in bowel habit Abdominal pain Polyp surveillance IBD assessment / surveillance

Clinical details

Safety details

Anticoagulants / antiplatelets

Diabetes medications

Allergies

Anaesthetic / sedation concerns

Other relevant medical history

Supporting documents

Upload referral letter, reports, or other relevant documents

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