Specialised Procedures Request

Requested Procedure *

Endoscopic UltrasoundEUS + biopsyERCPFibroscanEMR/ESDBarrett’s EndotherapyBalloon EnteroscopyCapsule Endoscopy

Referral To *

Dr Saurabh GuptaDr Simmi ZahidDr Thao LamDr Rose Trieu

Patient's Details

Title *

First Name *

Last Name *

Date of Birth *

Address *

Suburb *

State / Territory *

Postcode *

Mobile Phone

Work Phone

Medicare

Exp Date

Private Health Fund

Membership Number

Clinical Information

Reason for Referral *

Pancreatic lesion (cyst/mass)Submucosal lesionBiliary obstructionSuspected small bowel bleedingLarge colonic polyp(s)Barrett’s with dysplasiaAbnormal LFTDysphagiaOther

Past Medical History

Heart conditionRespiratory diseaseDiabetesRenal impairmentLiver diseaseOther

Please describe

Medication

AnticoagulantAntiplateletAnti-arrhythmic agentInsulinAllergies

Anticoagulant

Antiplatelet

Anti-arrhythmic agent

Insulin

Allergies

Referring Doctor

Title *

First Name *

Last Name *

Address *

Suburb *

State / Territory *

Postcode *

Phone Number *

Fax Number

Provider Number *

Date of Referral *

Email Address *

Signature *

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Our practice nurse will contact the patient to arrange procedure booking or consultation.

IF APPLICABLE, PLEASE REQUEST PATIENTS TO BRING ALL PATHOLOGY, IMAGING AND ENDOSCOPY RESULTS WITH THEM FOR THE APPOINTMENT OR PROCEDURE.

For further enquiries, please contact T: (02) 9480 6210 F: (02) 8008 1625 E: admin@gastroandliver.com.au

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Sydney Gastroenterology and Liver Group

Suite 213, San Clinic Tulloch
Sydney Adventist Hospital
185 Fox Valley Rd
Wahroonga NSW 2076