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Refer a Patient

To refer a patient, please fill in all fields in the form below then press the “Submit Referral” button.

Refer a Patient

Patient Details

Date

Patient Name

Date of Birth

Telephone Number

Email Address

Medical Insurance Status

Private Health Insurance or DVA

Medicare

GP Details

Referring Doctor Name

Provider Number

Telephone Number

Email Address

Services Required

Consultation

Endoscopic Procedure

Direct Access Endoscopy (A/Prof Sujie will need to review the referral to approve)

Indication for Procedure/Consultation

Procedures

Diagnostic Endoscopy
Capsule Endoscopy
ERCP: Endoscopic Retrograde Cholangiopancreatograpy
EUS: Endoscopic Ultrasound
Tissue Resection
Barrett’s Oesophagus Management
Multi-disciplinary Cancer Management

Get In Touch

reception@silkmedical.com.au
(03) 9792 1191
(03) 9792 4257
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