OPEN ACCESS ENDOSCOPY
St Andrew's Ipswich Private Hospital, Cnr Roderick & Pring Streets, Ipswich QLD 4305
Phone: 07 3816 9915 | Fax: 07 3816 9918 | Medical Objects ID: AS4305006U5

N.B. Patients who have the following indicators require a consultation appointment with a Gastroenterologist or Surgeon prior to a procedure; they are not eligible for St Andrew's Open Access Endoscopy Clinic.
•	Patients on Warfarin | •	Diabetes
•	Moderate to severe heart disease | •	Patients on any blood thinners (other than Aspirin)

Please contact our clinical staff or doctors directly should you have any questions or concerns.
Dr John Copp | P: 3282 9319 | GS | Dr Natalie Kiel | P: 1800 199 920 | G
Dr Mark Cornwell | P: 3812 1222 | G | Dr Reuben Ndegwa | P: 1800 199 920 | GS
Dr M Waqas Fazal | P: 3517 4301 | G | Dr M Asif Shahzad | P: 3517 4301 | G
Dr Michael Fish | P: 3282 8556 | GS | Dr Raphael Varghese | P: 3137 0115 | CR
Dr Jane Ghadiri | P: 3077 7277 | GS | Dr Man-Shun Wong | P: 3282 9319 | GS
Dr Terry Holt | P: 3812 1222 | | Dr Xuan Banh | P:1800 199 920 | G
Dr Omar Mansour | P: 3444 1910 | GS | Dr Baillie Ferris | P: 3816 9188 | GS
Dr Jennie Gu | P: 3816 9188 | GS | | |
CR - Colorectal Surgeon | G - Gastroenterologist | GS - General Surgeon

Referral Details
I refer to: | <<Pratitioner>>
Referral to other: | <Referral to other:>
Referring doctor: | <<Doctor:Name>>
Referring address: | <<Doctor:Full Address>>
Referring phone: | <<Doctor:Phone>>
Referring fax: | <<Doctor:Fax>>
Provider number: | <<Doctor:Provider Number>>

Patient Details
Patient name: | <<Patient Demographics:Full Name>>
Date of birth: | <<Patient Demographics:DOB>>
Address: | <<Patient Demographics:Address>>
Home phone: | <<Patient Demographics:Phone (Home)>>
Mobile: | <<Patient Demographics:Phone (Mobile)>>
Medicare number: | <<Patient Demographics:Medicare Number>><<Patient Demographics:Medicare Expiry Date>>
DVA number: | <<Patient Demographics:DVA Number>>

Insurance Details
Health Insurance | <<Patient Demographics:Health Insurance>>

N.B. Patient must obtain estimate of costs  by making direct contact with the Specialist, Anaesthetist and Hospital. Payment must be made within 3 days prior to their procedure. For further information please phone 
07 3816 9915.

As per Queensland Health Colonoscopy Services Guidelines November 2019, please select item code that best indicates patient need for endoscopy procedure.
Item code: | <Indication>

Alerts
Allergies: | <<Clinical Details:Allergies/Adverse Reactions>>
Infectious status: |

Other:

Is the Patient on blood thinners: <<Is the Patient on blood thinners (other than Aspirin)>>
Is the Patient on Warfarin:<<Is the Patient on Warfarin>>
Does the Patient have Diabetes: <<Does the Patient have diabetes>>
Does the Patient have moderate to severe heart disease<<Does the Pt have moderate to severe heart disease>>
If you have answwere yes to any of the indications the patient will need to be referred to a gastroenterolgist prior to the procedure. They are not eligible for St Andrew's Open Access Endoscopy Clinic

Medications:

<<Clinical Details:Medication List>>

GP signature: | _______________
Date: | <<Miscellaneous:Date>>

Please fax completed referral to St Andrew's Ipswich Private Hospital on 07 3816 9918 
OR send via Medical Objects ID: AS4305006U5

Hospital/Pre-admission Use Only
Patient: | <<Patient Demographics:Full Name>>
Fax received: |
Patient phoned: |
Booked for: |
Faxed to Specialist: |
Faxed to Anaesthetist: |
Faxed to office: |
Patient advised to fast from: | Time:           AM/PM

Patients scheduled for colonoscopy will be required to attend a pre-admission clinic to collect diet instructions and bowel preparation three days prior to their procedure:
MR2: Yes/No | Instructions: Yes/No | Collected prep: Yes/No

Open Access Endoscopy Referral Template Version 2.0
Reviewed 20042022
Approved by Michael Lewczuk  CEO
THIS DOCUMENT IS UNCONTROLLED IF PRINTED