THS North West
Public Direct Access Endoscopy Service	
Referral to:	  Referring General Practitioner:	
	NWAHS Public Direct Access Endoscopy Service
Mersey Community Hospital
Bass Highway
Latrobe TAS 7307
Phone: 6478 5390   Fax:  6426 5442
Email: daes@ths.tas.gov.au	<<Doctor:Name>>
<<Practice:Name>>
<<Doctor:Full Address>>
Phone: <<Doctor:Phone>>  Fax: <<Doctor:Fax>> 
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>

Referral Date:    <<Miscellaneous:Date (short)>>	
<<NB>>

Patient Details:		
Name:	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of Birth:	<<Patient Demographics:DOB>>
Contact Address:	<<Patient Demographics:Address>>
	<<Patient Demographics:City>>  <<Patient Demographics:State>>    <<Patient Demographics:Postcode>>
Phone:	<<Patient Demographics:Phone (Home)>>
Work:	<<Patient Demographics:Phone (Work)>>
Mobile:	<<Patient Demographics:Phone (Mobile)>>	Pension Card Number: <<Patient Demographics:Pension Number>>
Medicare Number: <<Patient Demographics:Medicare Number>>
DVA Number: <<Patient Demographics:DVA Number>>
IHI Number: <<Patient Demographics:IHI>>  
Insurance:  <<Does the patient have Private Insurance>>
Emergency Contact:
Name:  <<Emergency Contact Name>>
Phone:  <<Emergency Contact Phone>>

Patient's Usual GP:  <<Doctor:Name>>	

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.

		q <<Patient Demographics:Title>> <<Patient Demographics:Surname>> 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 & Reason for Urgency:	<<Urgency _State 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? (if Yes, which type) 	<<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>>	

		<<Patient Demographics:Title>> <<Patient Demographics:Surname>> 	
		 is aware that he/she will be managedby the next available consultant within this service.  <<Patient Demographics:First Name>> 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:		
<<Patient Demographics:First Name>> <<Patient Demographics:Surname>> DOB:  <<Patient Demographics:DOB>>

Progress Notes: 
<<Summary:Progress Notes (Selected)>>

Warnings: <<Clinical Details:Warnings>>

Allergies:  <<Clinical Details:Allergies>>

Current Medication:
<<Clinical Details:Medication List>>

Family History: 
<<Clinical Details:Family History>>

Past Medical History:
<<Clinical Details:History List>>

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

Investigation Results:
<<Summary:Investigation Results (Selected)>>

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

yours sincerely,

<<Doctor:Name>>   Signature:......................................................Date:<<Miscellaneous:Date (short)>>