Gastroenterology Referral Form
Patient details: 
First name: <PtFirstName>
Surname: <PtSurname>
Address: <PtAddress>
Home phone:  <PtPhoneH>
Mob phone: <PtPhoneMob>
DOB: <PtDoB>	

MBBS BMedSci FRACP
Provider No. 264383	
Request:
<Consultation > Consultation
<Colonoscopy > Colonoscopy
<Gastroscopy> Gastroscopy
Current medications and alerts:
<SelectedRx>
Allergies: <Reactions>
<Diabetes> Diabetes - on tablets or insulin (please circle)
<Anti-platelet agents> Anticoagulants - warfarin, Plavix, Xarelto, Eliquis, other
<Renal impairment > Renal impairment
Clinical details:
<SelectedPMH>
Referring Doctor’s details:
Doctor’s name: <UsrDetails>
Phone: <DrPhone>
Provider number:<DrProviderNo>
Signature:
Date:<TodaysDate>

Phone: 07 3193 0877 Fax: 07 3319 6466 Email: reception@drjasonhuang.com.au                   
                      www.drjasonhuang.com.au	
Locations:
St Andrew’s War Memorial Hospital Sessional Suites, Level 4
457 Wickham Terrace
Brisbane QLD 4001	Holy Spirit Northside Private Hospital Arnold Janssen Building, Suite 15, Level 1 627 Rode Road
Chermside QLD 4032	
Correspondence: PO Box 206, Ashgrove QLD 4060	
        For all appointments please call: 07 3193 0877            	
Locations:	
St Andrew’s War Memorial Hospital Sessional Suites, Level 4, Yellow lifts, 457 Wickham Terrace
Brisbane QLD 4001	Holy Spirit Northside Private Hospital Arnold Janssen Building, Suite 15, Level 1 627 Rode Road
Chermside QLD 4032	

	

 	
Notes: