Refer a patient - Gastroenterology & Metabolic Specialists

Patient Details

First Name

Surname

Email Address *

Phone Number

Date of birth

Day

Month

Year

Address

Services

Please tick the required service(s)Gastroenterology or Hepatology ConsultationFibroscan® ConsultationMetabolic Health ConsultationIron InfusionOpen Access Gastroscopy**Open Access Colonoscopy**

** Patients with any of the following will require a referral for consultation prior to endoscopy:

Age > 70 years
Significant cardiac or respiratory disease
Diabetics (on oral medication or insulin)
Blood thinning medication other than aspirin
BMI > 40 k g/m2

Indication for Referral

Please tick the relevant indications and attach relevant supporting clinical history / investigationsInflammatory bowel diseaseIrritable bowel syndromeRectal bleeding / positive FOBTMetabolic dysfunctionCoeliac diseaseIron deficiency ± anaemiaOther (please specify below)

Other indications:

Medical Comorbidities

Referring Doctor Details

Doctor Name

Provider number

Practice Name

Practice Address

Preferred Location

LocationMasada Private Hospital (St Kilda East)Holmesglen Private Hospital (Moorabbin)

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Clinician Referrals

Online Referral Form for Health Practitioners

Patient Details

Services

Indication for Referral

Referring Doctor Details

Preferred Location