Referral for:  	
<<Referral for>>	

Reason for Referral (must select one):	
<<Reason for Referral>>	
If other please 
specify	
<<if other please specify>>	

For Clinical assessment or other procedures (e.g. ERCP, EUS) please use the CRS General Adult Outpatient form.
For guidance on referral guidelines, refer to the HealthPathways (https://wa.communityhealthpathways.org/) or Referral Access Criteria (https://ww2.health.wa.gov.au/Articles/N_R/Referral-Access-Criteria) websites.
Patients who require immediate attention (i.e. within 7 days) should NOT be referred via the Central Referral Service - contact the Gastroenterology service at the nearest site for advice.
For referrals to WACHS hospitals, please forward directly to the relevant site.	
Patient Details	
First name:	
<<Patient Demographics:First Name>>	

Family 
name:	
<<Patient Demographics:Surname>>	

Maiden Name/Alias:	
<<Maiden Name/Alias:>>	

	

DOB:	
<<Patient Demographics:DOB>>	

Sex:	
<<Sex>>	

	

Address:	
<<Patient Demographics:Full Address>>	

	

Suburb: 	
<<Patient Demographics:City>><<Patient Demographics:State>>	

	

Postcode:	
<<Patient Demographics:Postcode>>	

	

Home no:	
<<Patient Demographics:Phone (Home)>>	

	

Work no:	
<<Patient Demographics:Phone (Work)>>	

	

Mobile:	
<<Patient Demographics:Phone (Mobile)>>	

	

Email: 	
<<Patient Demographics:E-mail>>	

	

Medicare no:	
<<Patient Demographics:Medicare Number>>	

	

Ref:	

	

Expiry:	
<<Patient Demographics:Medicare Expiry Date>>	

	

Next of Kin:	
<<Patient Demographics:Next of Kin>>	

	

Contact no:	
<<Patient Demographics:Next of Kin Phone>>	

	

Interpreter required:	
<<Interpreter required>>	

	

Language:	
<<Patient Demographics:Language Preferred>>	

	

Indigenous status:	
<<Indigenous status>>	

	

Patient available at       
short notice (<3 days):	
<<Patient available at short notice (<3 days)>>	

	

	

  Referrer Details
Name	
<<Doctor:Name>>	

Provider No.	
<<Doctor:Provider Number>>	

Telephone No.	
<<Doctor:Phone>>	

Fax No.	
<<Doctor:Fax>>	

Address	
<<Doctor:Full Address>>	

Date   	
<<Miscellaneous:Date>>	
Signature:	

	

	

Lower GI indications 
for endoscopy: 
(MUST tick at least one 
box and attached relevant 
evidence/provide comment 
as indicated if referring for 
colonoscopy or referral 
will be returned)	

	
Rectal bleeding (multiple occurrences or continuous) for >4 weeks (specify time and
no. of episodes below)	

	
+iFOBT where a colonoscopy has not been performed within last 2 years (attach results)	

	
Altered bowel habit >6 weeks AND in presence of alarm symptoms (provide 
description and must select at least one alarm symptom below)	

	
Altered bowel habit >6 weeks AND age>=45 (provide description)

	

Diarrhoea >6 weeks with negative stool culture (attach MC&S results)

	

Unexplained iron deficiency +/- anaemia (attach FBC results)

	

Mass or abnormal imaging (attach report)

	

After first episode of proven diverticulitis to exclude neoplasm

	

Surveillance procedures required within 12 months (specify reason & attach reports)

	

Alarm symptoms for
lower GI endoscopy:
(informs triage- tick all that
apply and attach evidence/
provide detail)

	
Persistent rectal bleeding

	

Unexplained progressive weight loss 

	

Bloody diarrhoea with negative stool MC&S

	

	
Persistent severe abdominal pain

	

Unexplained iron deficiency anaemia	

Lower GI comments /
evidence to support
indications:

<<Lower GI comments evidence to support indication>>

	

Upper GI Indications
for Endoscopy:
(MUST tick at least one box
and attached relevant
evidence/provide comment
as indicated if referring for
gastroscopy or referral will
be returned)	

	
Unexplained iron deficiency +/- anaemia (attach FBC results)

	

Unexplained recent dyspepsia AND in presence of alarm symptoms (select at
least 1 alarm symptom below)	

	
Non-responsive GORD

	

Persistent or recurrent (>=4 weeks) dysphagia (specify time and no. of episodes)

	

Mass or abnormal imaging (attach report)

	

Upper abdominal pain AND unexplained weight loss OR abnormal blood test (describe symptoms and attach results)

	

Persistent nausea/vomiting AND unexplained weight loss OR abnormal blood test (describe symptoms and attach results)

	

Suspected Coeliac disease with positive serology (attach results)

	

Known Coeliac disease with no exposure to gluten AND persistent high titres after 12 months OR in presence of alarm symptoms (select at least 1 alarm symptom below)	

	
Pernicious anaemia (serologically diagnosed), asymptomatic at time of diagnosis (attach results)	

	
Surveillance procedures required within 12 months or requested by previous endoscopist (specify reason and attach reports)

	

Alarm symptoms for
Upper GI Endoscopy:
(informs triage- tick all that
apply and attach evidence/
provide detail)

	
Gastrointestinal bleeding

	

Unexplained progressive weight loss

	

Unexplained iron deficiency anaemia

	

	
Dysphagia

	

Early satiety	

	
Upper GI Comments/ evidence to support indications	
<<Upper GI Comments/evidence to support indication>>

	

Medical History and Risk Factors
Height (cm):	
<<Height (cm)>>	
Weight (kg):	
<<Weight (kg)>>	
(Estimate if not known)	

	

	
Bleeding disorder (specify below)

		

Kidney disease (Attach recent 
U&E)	

	
Pacemaker in situ	

	

Neurological history (specify below)

		

Recent surgery (specify below)

		

Cardiac stents in situ	

	

Significant lung/airway disease

		

Obstructive sleep apnoea 

		

Implanted defibrillator in situ
For any of above in situ	

	

Liver disease (attach recent LFT/INR/ platelets)	

	
Heart Disease

		

items, specify when
> 1 year	

	
<1 year	

	

	

	
Diabetes

		

Previous CVA	

	

Type	
<<Diabetes type>>	

	

	
None	

Additional Medical
History Details:	 
 <<Additional medical history details:>>

	

Special
Considerations:

	
Significant alcohol
history

	

	
Significant illicit 
drug history

	

	
Significant mental
health issues

	

	
Other social factors e.g. homeless (detail below)

	

	
Department of
Justice patient	

	

Nursing home
patient

	

	
Other / Comments:	 <<other/comments>>

	
Is the Patient taking any anti-coagulant or anti-platelet medication/s, including Aspirin?
Yes	

	
No	

	

If yes, please specify drug and reason (and include any relevant documentation from other specialists:	

	
	
Current medication:
Please list all medications
patient is currently taking,
or attach summary	 <<Clinical Details:Medication List>>

	

	
Allergies / Reactions 
(inc. latex, tapes etc.):
	
<<Clinical Details:Allergies/Adverse Reactions>>

	
Nil known	

	

	
Relevant 
Investigations - 
Please provide date 
and findings, or attach report:	 <<Relevant Investigations>>

	

Other Comments:	<<Other Comments:>>

	

	
	
Once completed, please send referral to the Central Referral Service by one of the following methods:
(Please note that for efficiency of processing your referral, our preferred method is Secure Messaging)
Secure Messaging:	
Healthlink address ID: crefserv	

Fax:	
1300 365 056	

Post:	
Central Referral Service, GPO Box 2566, St Georges Terrace, WA 6831	

Hospital Use Only	
Triage Outcome:
Category 1	
c	

Category 2	
c	

Surveillance (Staged Cat 2)	
c	
Date Due:	

	

Return to Referrer (Specify below)	
c	

Forward to other site:	

	

	Procedure:
Colonoscopy	
c	

Gastroscopy	
c	

Flexi sigmoidoscopy	
c	

	
c	

	Admission Type:
Same Day:	
c	

Overnight:	
c	

                  	Other requirements:
PAC telephone	
c	

PAC in person	
c	

Anaesthetic list	
c	

Comments:

	
Name:

Designation:
	Signature: 	Date: <<Miscellaneous:Date>>	

Request for Direct Access Gastrointestinal Endoscopy form last updated: June 2022
Review date: June 2024