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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