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Hillsborough Private Clinic is a Leading Provider of Independent Healthcare Services

NI: (028) 9268 8899

ROI: (048) 9268 8899

GP Referrals

Home
Services & Treatments
Consultants
Patient information
Job Opportunities
Privacy Policy
Contact us

Direct Access OGD Referral

Direct referrals can be made here for OGDs.

PRINT OGD PATIENT INFO

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Direct Access OGD Referral

PATIENT NAME (required)

H&C NUMBER (required)

ADDRESS (required)

DATE OF BIRTH (required)

AGE (required)

SEX (required)

MaleFemale

HOME PHONE (required)

WORK PHONE

SYMPTOMS

IndigestionAbdominal painReflux symptomsChange in dyspepsiaVomitingDysphagia/odynophagiaHaematemesis/ melaenaIron deficiency anaemiaWeight loss>3 kgEarly satietyAbnormal Barium meal

REASON FOR REFERRAL (required)

RISK FACTORS

Previous gastric surgeryBarrett’s oesophagusFamily history of upper GI cancerPrevious gastric ulcer

HELICOBACTER STATUS

PositiveNegativeUnknown

HAS HAD HELICOBACTER ERADICATION?

YesNoUnknown

ULCER HEALING DRUGS IN LAST 3 MONTHS?

YesNoUnknown

CO MORBIDITY

Cardio-respiratory diseaseProsthetic heart valveOn anticoagulantsRecent myocardial infarction (6 months)Tablet or diet controlled diabetesInsulin controlled diabetesSevere obesity

REFERRING DOCTOR (required)

MEDICAL PRACTICE (required)

DATE (required)

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Hillsborough Private Clinic

Hillsborough Private Clinic is a leading provider of independent healthcare services. The clinic offers access to outpatient consultations, modern technology and advanced surgical procedures in a personal yet professional atmosphere.

NI (028) 9268 8899

ROI (048) 9268 8899