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:  <<Patient Demographics:Full Name>>	
 Address: <<Patient Demographics:Address>>  <<Patient Demographics:Postcode>>  <<Patient Demographics:State>>	
 Phone:  (h) <<Patient Demographics:Phone (Home)>> (m) <<Patient Demographics:Phone (Mobile)>>	
 D.O.B. <<Patient Demographics:DOB>>         Health Fund: <<Patient Demographics:Health Insurance>>	
 Medicare: <<Patient Demographics:Medicare Number>>  <<Patient Demographics:Medicare Expiry Date>>	

 Clinical Indicators:  <<Clinical Details:History List>>	
 Medications: <<Clinical Details:Medication List>>	
 Allergies: <<Clinical Details:Allergies/Adverse Reactions>>	

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

Referring Doctor	
 Name:   <<Doctor:Name>>           Provider N.O. <<Doctor:Provider Number>>	
 Address:   <<Doctor:Address>>  <<Doctor:City>>  <<Doctor:Postcode>>	
 Phone:  <<Doctor:Phone>>	

Signature:                                                     Date: <<Miscellaneous:Date (short)>>	

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