General Referral

Use this form for colorectal surgical review, bowel symptoms, anorectal conditions, pelvic floor concerns, suspected malignancy, diverticular disease, inflammatory bowel disease, or other specialist colorectal advice.

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

Patient address

Referral reason

Urgency

Preferred hospital / location

Reason for referral

Bowel cancer / suspected malignancy Rectal bleeding Diverticular disease Inflammatory bowel disease Haemorrhoids Anal fissure / fistula / abscess Pelvic floor / functional bowel concern Other

Clinical summary

Red flags / key concerns

Medical background

Relevant past medical / surgical history

Medications, anticoagulants / antiplatelets, and allergies

Investigations attached / to follow

Supporting documents

Upload referral letter, reports, or other relevant documents

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