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Referral22022017 Dr Keong Lim MBBS (Hons), FRACP Dr Kee Ooi MBBS, FRACP Dr Linus Chang MBBS (Hons), MRCP, FRACP Dr Sean Szetoo MBBS, FRACP CONSULTANT GASTROENTEROLOGISTS & PHYSICIANS LOGAN ENDOSCOPY Westpac House Unit 2, 3276 Mt Lindesay Hwy (Beaudesert Rd) Between Browns Plains Rd & Janita Dr BROWNS PLAINS 4118 PATIENT’S NAME ………………………………….. CONTACT NO: ………………… DOB: …../…./…… CLINICAL HISTORY & CURRENT THERAPY ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………................ Consultation Warfarin Aspirin Gastroscopy & pre test consultation Anticoagulants Plavix/Iscover No food for 8 hours, no water or fluids for 6 hours before procedure. If you must take prescription medications (except diabetic medication), this can be taken up until 4 hours before procedure with a small sip of water. Colonoscopy & pre test consultation (Special preparations & instructions given at time of consultation) Referring Dr………………………… Signature …………………………… ……………………………………… ………………………………………. Provider No ................................... Date: …………………………… This Referral Must Be Produced At Time Of Appointment Appointments: (07) 3809 2893 Mobile: 0481 394 818 Fax: (07) 3809 2895 Website: loganendoscopy.com.au Email: [email protected]
