Doctor Referral

Dear Dr Gastroenterology,

I would like to refer the following patient

Patient Details
Patient Name*
Patient Phone Number*
Patient Date of Birth*
Date Format: DD slash MM slash YYYY
To your practice rooms at:
- 493 Ballarat Road, Sunshine
- 15 Munro St, Coburg
- Wyndham Private Specialist Consulting Suites, Werribee
- 42 The Avenue Windsor
- QV Melbourne - Level 3, 292 Swanston Street
Preferred Doctor:
- Dr. Ian KC Fok
- Dr. Abed Azizi
- Dr. Kenneth Hon
- Dr. Cuong Duong
Proceedure Details
Please provide referral summary below
For consideration of
- Open Access Pillcam
- Open Access Gastroscopy
- Open Access Colonoscopy
- Open Access Iron Infusion
- Consultation
- Helicobacter pylori Breath testing
- Oesophageal Impedance-pH study
- Hydrogen Breath Testing
Hydrogen Breath Test Type
- Lactulose
- Lactose
- Fructose
- Sorbitol
- Inulin
- Glucose
Referring Doctor Details
Referring Doctor*
Provider Number*
Phone Number*
Address*
Email
If you would like to receive a copy, please enter your email address
Urgent Referrals
If referral is urgent please get pt to call 90444200 and advise reception that the referral is urgent.
We are open from 8am to 5pm Mondays to Fridays for urgent referrals and aim to see all Urgents within 72 hours
- Urgent Referral
Confirmation*
- I confirm that all details above are true and correct

PLEASE NOTE: Your IP address (207.241.232.245) and time/date form submitted will be displayed on the confirmation page.

Patient Details