Surname:
Given Names:
Rapid Access to Gastrointestinal Endoscopy (RAGE)
Referral Form
For further information please review the Rapid Access to Endscopy Pathways and other clinical information available here
http://www.westernhealth.org.au/HealthProfessionals/ForGPs/Pages/Endoscopy.aspx
Patient details
Referring doctor details
Name:
Date of Birth:
Sex:
Address:
Suburb:
Phone (Home)
Mobile:
Medicare Number:
Name:
Practice:
Practice Address:
Suburb:
Phone:
Provider number
Date:
Postcode:
Phone (Work)
Is an interpreter required? 
No
Yes
Language:
Postcode:
Fax:
Signature
Request for endoscopy:
Gastroscopy – Indications provide details below Colonoscopy – Indications provide details below
BLEEDING
Haematemesis
Melaena
Iron deficiency anaemia (attach FBE / Fe studies)
BLEEDING
Positive FOBT NBCSP Other 
Blood in stools Bright Dark / mixed
Iron Deficiency Anaemia (attach FBE / Fe studies)
SUSPECTED MALIGNANCY
Unintentional weight loss
Dysphagia
Persistent nausea or vomiting
Loss of appetite
Epigastric pain
Abnormal imaging (attach report)
Other (details below)
SUSPECTED MALIGNANCY
Change in bowel habit (constipation or loose stools)
Unintentional weight loss
Rectal or abdominal mass
Abdominal pain
Abnormal imaging (attach report)
Known large polyp requiring removal
(attach colonoscopy and path reports)
 Other (details below)
Additional clinical information to assist with determining urgency of the procedure:
Please include details about risk factors (family history of gastro-intestinal malignancy, personal history of alcohol excess or
smoking), relevant personal past medical history (e.g. Barrett’s oesophagus, inflammatory bowel disease, DVT in last year,
previous malignancy)
GP Name:
Patient Name:
Referral Date:
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Anti-Coagulation / Anti-Platelet Therapy*:
None
Clopidogrel

Warfarin
Dabigatran (Pradaxa), Rivaroxaban (Xarelto)
Apixaban (Eliquist)

Prasugrel (Effient), Ticagrelor (Brilinta)
Can it be stopped
Comments
Yes No Unsure
Yes No Unsure
Yes No Unsure
Yes No Unsure
Yes No Unsure
*Aspirin can nearly always be continued 
Current Medications
Relevant Past Medical History
Allergies
Has the patient had a previous colonoscopy?
No
Yes – Date:
(please attach colonoscopy report and pathology report)
Has the patient had a previous gastroscopy?
No
Yes – Date:
(please attach gastroscopy report and pathology report)
Does this patient have an increased risk for sedation or anaesthetic?
No
Yes – Comments:
What is the patient’s Body Mass Index (BMI)?
Does the patient suffer from constipation? (This will help determine the appropriate bowel preparation)
No
Yes
Please fax referral to 8345 7378. Incomplete referrals will be returned to the referring doctor.
All referrals made using this RAGE referral form will be triaged by a Western Health Medical
Practitioner to determine whether the patient meets the criteria for a category 1 procedure or
whether they will be waitlisted for an outpatient clinic review.
Patients will be sent a health questionnaire – this must be completed before a booking will be made.
For any booking enquiries phone 8345 6015.
For clinical queries please contact the Endoscopy Registrar via switch 8345 6666
GP Name:
Patient Name:
Referral Date:
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GP Name:
Patient Name:
Referral Date:
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