Gastroenterology Referral Form
Patient details: 
First name: <<Patient Demographics:First Name>>
Surname: <<Patient Demographics:Surname>>
Address: <<Patient Demographics:Address>>
State: <<Patient Demographics:State>>
Postcode: <<Patient Demographics:Postcode>>
Phone: <<Patient Demographics:Phone (Mobile)>>
DOB: <<Patient Demographics:DOB>>	

MBBS BMedSci FRACP
Provider No. 264383	
Request:
<<Consultation >> Consultation
<<Colonoscopy >>Colonoscopy
<<Gastroscopy>> Gastroscopy
Current medications and alerts:
<<Clinical Details:Allergies>> <<Clinical Details:Medication List>>
<<Diabetes>> Diabetes - on tablets or insulin (please circle)
<<Anti-platelet agents>> Anticoagulants - warfarin, Plavix, Xarelto, Eliquis, other
<<Renal impairment >> Renal impairment
Clinical details:
<<Clinical Details:History List>>
Referring Doctor’s details:
Doctor’s name: <<Doctor:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Provider number: <<Doctor:Provider Number>>
Signature:
Date: <<Miscellaneous:Date (short)>>
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: