Mr Tobias Evans
MBBS FRACS
COLORECTAL SURGEON
admin438@calvarycare.org.au
Healthlink EDI: chctlvcs                	Calvary Health Care Tasmania
438 Elizabeth Street
North Hobart  TAS  7000
Phone Number 6234 5302
Fax: 6234 8565
	
DIRECT  ACCESS  GASTROSCOPY  AND  COLONOSCOPY	

Examination:	 <Gastroscopy> 	 Gastroscopy	 <Colonoscopy> 	Colonoscopy	

Patient:	
	
 Name:  <PtName>	
 Address: <PtStreet>  <PtPostcode>  <PtState>	
 Phone:  (h) <PtPhoneH> (m) <PtPhoneMob>	
 D.O.B. <PtDoB>         Health Fund: <PtHealthIns>	
 Medicare: <PtMCNo>  <PtMCLine>   <PtMCExpiry>	

 Clinical Indicators:  <SelectedPMH>	
 Medications: <SelectedRx>	
 Allergies: <Reactions>	

Please Notify:	 Anticoagulation	 <Anticoagulation>	
	 Clopidogrel	 <Clopidogrel>	
	 Diabetic	 <Diabetic>	

Referring Doctor	
 Name:   <DrName>           Provider N.O. <DrProviderNo>	
 Address:   <DrStreet>  <DrCity>  <DrPostcode>	
 Phone:  <DrPhone>	

Signature:                                                     Date: <TodaysDate>	

Referral can be sent via Healthlink on EDI chctlvcs or emailed to admin438@calvarycare.org.au 
Reception staff will arrange directly with your patient.