Direct Access Referral

Direct access referrals are available for gastroscopy and/ or colonoscopy for any patient with private health insurance. Referrals may by made using our webform below, or by faxing your referral to (02) 8212 8192.

This webform is for use by referring doctors only – not patients.

Please note: items marked * indicate mandatory fields

GP/Specialist details

Referring Doctor Name *

Referring Doctor Practice Name

Referring Doctor Provider # *

Referring Doctor Address

Referring Doctor Suburb

Referring Doctor Postcode

Referring Doctor Phone *

Referring Doctor Email

Patient details

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Day

Month

Year

Patient phone *

Patient clinical condition / details *

Referred Procedure(s)

Colonoscopy

Gastroscopy

File Attachment

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf pdf doc docx xls xlsx.

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