FOBT Colonoscopy Referral Form
For public patients fax to 02 49 223 891
For private patients fax to the specialist's rooms
Patient Details	Date of Referral    <FormattedDate>	
Re:  <PtFullName>	DOB:  <PtDoB>	
Medicare No: <PtMCNo>	Ref No: <PtMCLine>              Expiry: <PtMCExpiry>	
Address: <PtAddress>	Pt Email: <PtEmail>	
Telephone Home: <PtPhoneH>
                 Mobile: <PtPhoneMob> 	Interpreter required?: <Interpreter required?>
Language: <Language>
Indigenous Status: <Indigenous Status>	
Is the patient privately insured?  <Is the patient privately insured?>	

One Endoscopist (Surgeon* or Gastroenterologist) must be selected from the drop down list: <Select One Endoscopist (Surgeon* or Gastroenterologist)>	
Are you happy for the patient to see the next available Endoscopist: <Happy for the patient to see the next available Endoscopist?>	

Relevant Medical History and Risk Factors For Procedure	
Did this patient have a +ve FOBT result?  <Did this patient have a +ve FOBT result?>
Please attach the FOBT result and other relevant results	
Mandatory   Weight (kg):  <Weight (kg)>               Height (cm): <Height (cm)>	
Please indicate the following	Yes	Indicate current medications	Yes	
Heart conditions		Warfarin	¨	
Pacemaker	¨	INR	Date    /   /  	
Angina	¨	Clopidogrel	¨	
Atrial Fibrillation	¨	Dabigatran or Rivaroxaban	¨	
CHADS2 Score
Heart failure 1pt, H/T 1pt, Age>75 1pt, diabetes 1pt, 
Stroke or TIA 2pts		Aspirin	¨	
Artifical heart valve	¨	Other oral anticoagulants?	¨	
Implantable defibrillators	¨			
Diabetes		NSAIDS	¨	
Type 1	¨	Iron tablets	¨	
Type 2	¨			
Insulin	¨	Allergies  <Reactions>	
Renal Failure
  If yes what is the eGFR:	¨	ETOH  <AlcHx>	
Liver disease	¨	Current Smoker  <SmkStatus>	
All public patients with a positive FOBT in the Greater Newcastle Region are referred directly to the Colorectal Coordinator using this fan number 02 49 223 891. The Colorectal Coordinator will assess the referral to determine if the patient is suitable for direct access colonoscopy in the pubic system.
Privately insured patients can be referred directly to private rooms by faxing this form to rooms directly, please indicate (above) if the patient is privately insured.	

Referring Doctor - Practice Stamp or details
<DrDetails> Ph:  <DrPhone>      Fax:  <DrFax>
Provider No: <DrProviderNo>
	Doctors Signature: