Online Referrals


FOR COMPLETION BY REFERRING DOCTORS ONLY.

Referrals may also be faxed to (03) 6301 9234.
We are Healthlink enabled to facilitate paperless, secure and rapid communication.
Open access endoscopy is available for appropriate patients.

 

PLEASE NOTE:  The bug affecting this form has now been resolved, and it is working as expected.  Thank you for your patience.

    Referring Doctor (required)

    Provider number (required)

    Doctor's Contact number

    Email address

    Title

    Patient First Name

    Patient Last Name

    Date of Birth

    Home phone

    Mobile

    Address

    Reason for Referral (check all that apply)
    ConsultationColonoscopyGastroscopyEndoscopic UltrasoundERCP

    Patient History

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