The Digestive Health Centre
90 David Street Dandenong
Tel: 03 9791 8788  Fax: 03 9792 1508
http://www.digestivehealth.com.au/
Referral Form
Patient Details
Name: <<Patient Demographics:Full Name>>
DOB: 	<<Patient Demographics:DOB>>	Medicare number: <<Patient Demographics:Medicare Number>> 
Address: <<Patient Demographics:Address>>  <<Patient Demographics:City>> <<Patient Demographics:Postcode>>
Telephone: Work: <<Patient Demographics:Phone (Work)>> Home: <<Patient Demographics:Phone (Home)>> Mobile: <<Patient Demographics:Phone (Mobile)>>

Clinical Details

Services Requested  To select a service highlight the box and press the  “x” key:

q	Gastroscopy		q	Dietitian
q	Colonoscopy					q	Continence Physiotherapist	
q	Consultation (Adult)				q	Psychologist
q	Consultation (Paediatric)			q	Pill Cam (Capsule endoscopy)

Referring Doctor				Report – Preferred Method of Delivery		
 <<Doctor:Full Details>>	q	Argus Email
q	Promedicus
q	Post 
q	Facsimile	
																				Copy to:

Signature:					Date:       <<Miscellaneous:Date>>

All Appointments Telephone (03) 9791 8788   Facsimile (03) 9792 1508

Digestive Health Centre – Dandenong	90 David Street  Dandenong  3175	
St John of God Hospital	1 Gibb Street Berwick 3806	

q	Dr David Rubinstein		q	Dr Malcolm Barnes		q	Dr George Alex (Paed)
q	Dr Wayne Friedman		q	Dr Jacqui Dobson		q	Dr Rupert Hinds (Paed)