Dr Trina Kellar Referral Form

QLD Pelvic Floor Centre - RiverCity Private Hospital, 4/401 Milton Road, Auchenflower Q - Phone: 3193 7711

REFERRAL FORM

Dear Dr Trina Kellar,

Please accept the following referral for: *

Direct to upper GI endoscopyDirect to colonoscopyDirect to upper GI endoscopy + colonoscopy Consultation for Interventional Upper GI Endoscopy (eg. balloon dilatation, botulinum toxin)

Is this referral URGENT? *

Yes - Expected wait time < 4 weeks (if patient requires earlier scope, please contact Dr Kellar directly via 3646 8111)No

Patient Information

Surname *

Given Name *

Date of Birth *

Gender *

MaleFemaleOther

Phone - Mobile *

Summary of Referral

Relevant Surgical / Medical History:

Document Upload

Would you like to upload any documents with respect to this referral?

YesNo

File upload

Browse

Please upload a copy of your referral, medication list, previous correspondence, investigations results / reports that you would like to Qld Pelvic Floor Centre to review.

Relevant Medical History

Is the patient diabetic? *

NoYes - Type 1Yes - Type 2

Is the patient taking any of the following anticoagulant medications? *

Aspirin 100mg daily Clopidogrel (Plavix / CoPlavix), ticagrelor Warfarin (Coumadin) Apixaban (Eliquis) Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Dalteparin (Fragmin) Enoxaparin (Clexane) Heparin Other Not Applicable

Is the patient taking any of the following GLP-1 Receptor Agonists: *

Ozempic (semaglutide), Wegovy (semaglutide), Mounjaro (tirzepatide), Zepbound (tirzepatide), Saxenda (liraglutide), Liraglutide Sandoz Other Not Applicable

Medicare and Insurance

Does the patient have private health insurance with hospital cover?

YesNo

Does the patient have a Medicare number? *

YesNo

Referring Doctor

Referring Doctor Name *

Provider Number: *

Referring Doctor Practice Email Address: *

Date: *

Referrer Signature: *

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Thank you for your referral.

Dr Kellar's rooms will be in contact with your patient soon.

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