Specialised Procedures Request

Requested Procedure *

Endoscopic UltrasoundEUS + biopsyERCPFibroscanEMR/ESDBarrett’s EndotherapyBalloon EnteroscopyCapsule Endoscopy

Referral To *

Dr Saurabh GuptaDr Thao LamDr Rose TrieuDr Calvin Park

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

Anti-arrhythmic agentAnti-coagulantAnti-plateletInsulinOzempic / Wegovy / MounjaroALLERGIES

Radiology *

SanPRPiMedLumusOther / None

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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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