REFERRAL TO GASTROENTEROLOGY OUTPATIENT CLINIC 
•	Please fax or email this referral to (02) 8738 3094 or SWSLHD-LiverpoolGastro@health.nsw.gov.au
•	Please enter all details and provide relevant attachments. If referral is not complete, appointment allocation may be delayed.

New referral (patient not known to our service) o                 OR                  Re-referral (patient known to our service)  o 	

Referring Doctor details (complete or stamp)	
Name: 
		
Provider number:
		
Practice name & address: 
		
Phone:	Fax:	Email:	

Notify of patient appointment details   Y o      N o	Notify if patient does not attend appointment   Y o     N o	

Patient details (complete or affix sticker)	
Surname:
	Given name:	
Date of Birth:
	Sex:     Male o              Female o	
Address: 
		
Medicare Number: 		
Phone:		Email:	

Referral Details (ensure all sections are completed)	
Reason for referral/current problem: 

		
Past Medical History:

	

Current Medications: 

Allergies:
		
Phone:	Fax:	Email:	

Please include all previous investigations reports 	
□ Blood / stool tests	
□ Endoscopy	
□ Imaging