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Ipswich Hospital

General Surgical Outpatient Department
Please ensure that all relevant investigations accompany this referral.

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Ipswich Hospital Outpatient Clinic

Chelmsford Ave, Ipswich QLD 4305

PH: 07 3810 1111

Fax: 07 3810 1438
Date of Referral:

Is this an urgent or non urgent referral?
Reason for Referral ( Free Text ):

Include as much relevant information as possible about your patient's condition to optimise their chances of being triaged correctly eg diagnosis, duration, severity and impact.Please ensure all baseline investigations as per the pre referral guidelines accompany this referral. Test results should be dated within 3 months of referral date.


Practice Name:

Practice Address:

Practice HPI-O:




Provider Number:





Medicare Number*:

*[Medicare ineligible patients will incur an appointment fee]

Patient IHI:

Street Address:

Home Ph:

Mobile Ph:

Alternative Contact Name: Alt. Contact’s Phone:

[Alternative contact may be used to contact the patient if they cannot be reached via the contact details given]

Smoking Status:

Alcohol Status:

Social History:

Interpreter Required: please specify Language:

Is there results/investigations that will be faxed to the hospital to accompany this referral that could not be sent electronically?If yes, ensure all pages are clearly marked with the patients full name, date of birth and referring doctor and fax to: 07 3810 1438

Please use this guide to complete the appropriate tests and investigations so patients can be accurately triaged within the SURGICAL Outpatients Department.

All referrals should include:

  • complete patient / family history relevant to the patient’s condition or complaint

  • medication

  • known allergies

Please indicate if lifestyle modifications have been implemented as part of the overall management of the patient symptoms i.e. Smoking cessation, dietary modification, weight loss, increased exercise.

All investigation results are to accompany the patient referral when sent to SURGICAL Outpatients Department. Test results should be dated within three (3) months of referral date.

Diagnosis/ Symptomology

Baseline Investigations

All referrals

  • BMI

Gastro oesophageal Reflux

  • Duration

  • Previous gastroscopy dates/results

  • At least 3 months of PPI administered in community

    • Unless atypical symptoms such as respiratory (recurrent respiratory infections / asthma exacerbations)

    • Unless alarming symptoms i.e. dysphagia, weight loss

Upper Abdominal Pain


  • FBC, Coagulation studies, LFT

  • Drug history

PR Bleeding

  • Family history

  • Previous colonoscopy +/- gastroscopy dates / results

Iron Deficiency Anaemia

  • FBC, Iron Studies

  • FOB

Complex Varicose Veins


  • Thyroid function

  • Thyroid ultrasound scan NOT Isotope Scan

  • USS guided Biopsy and results - - required only in presence of dominant or solitary nodule


  • Ultrasound

  • Mammogram if >30 years of age

  • FNA


  • Ultrasound –adults only ( children should be referred to the Lady Cilento Children’s Hospital


  • BMI

  • Previous Surgical History

Colonoscopy Screening

  • Detailed family history

  • Age

  • Results / date of last colonoscopy

  • FOB / iron studies

Does the patient have a

current GP management

plan/team care



Please list any allied

Health providers

involved in the patients


Any other information

Is this a new or pre-existing condition:

Is the patient experiencing pain or a degree of loss of function due to this condition?

Relevant Medical History:


Current Medications:


Yours Sincerely

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