Melbourne Premier Gastroenterology | Online Referral Form

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Download a referral form

Patient eligibility criteria

This Referral Form is provided for GP use only and should not be used by patients.
Patients can complete an online appointment request here.

Online referral form

* Indicates required field

Your name (GP) *

Your details (required only if you are a first time referrer, or wish to update your info)

Email *

Telephone no. *

Fax no. *

Your provider number *

Preferred method of contact *

Patient Name *

Patient DOB *

Patient telephone no. *

Procedure requested *

Reason for Colonoscopy *

Colon cancer screening Positive FOBT PR bleeding Chronic diarrhoea Previous history of polyps Altered bowel habit Iron deficiency anaemia History of inflammatory bowel disease Other (please provide details below)

Reason for Gastroscopy *

Persistent reflux Abdominal pain Iron deficiency anaemia Dysphagia Melaena Nausea/vomiting Barrett's screen/follow up ?Coeliac disease Other (please provide details below)

Comments/further details *

Attach supporting documentation *

Max file size: 20MB

Submit

This Referral Form is provided for GP use only and should not be used by patients.Patients can complete an online appointment request here.

Online referral form

This Referral Form is provided for GP use only and should not be used by patients.
Patients can complete an online appointment request here.