Bowral Surgeons Rapid Access

I am a: *

DOCTOR referring a patientPATIENT with a referral from my doctor

When submitted, this form will be sent electronically to our practice and will act as the referral letter.

Preferred Date of Procedure (Thursdays or Fridays only)Where possible your procedure will be scheduled on your preferred date however there may be occasions where this is not possible and we may need to arrange an alternative date. This will be discussed with you at the time of booking.

Patient's Details

Title *

First Name *

Surname *

Date of Birth *

Patient's Phone *Best phone contact

Patient's Email Address *

Date of Referral *Please enter the date of the referral as shown in your doctor's letter

Referral file

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Please attach your referral file if you have one. Note the maximum size allowed is 10MB.

Referral for *

GastroscopyColonoscopyGastroscopy and Colonoscopy

Indication *

RefluxAbdominal PainChange in bowel habitFOBT positivePrevious polypsDysphagiaPR bleedingFamily historyAnaemia or iron deficiencyBarrett's surveillanceOther

Other

Other Clinical Details

Referring Doctor's Details

Title *

First Name *

Last Name *

Provider Number *

Your referring doctor's Provider Number will be listed on the referral form.

Referring Doctor's Address *

Address Line 2

Suburb *

State *

Postcode *

Referring Doctor's Phone *

Referring Doctor's Email *

Signature *

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Date

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Dr Joon Kim & Dr Michaella Smith
(02) 4861 7061
admin@bowralsurgeons.com.au
38 Bowral Street, Bowral NSW 2576