This form is intended for doctor referral use only

Dear Dr Gastroenterology,

I would like to refer the following patient

  • Patient Details

  • Date Format: DD slash MM slash YYYY

  • Proceedure Details


  • Referring Doctor Details

  • If you would like to receive a copy, please enter your email address
  • 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

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