ELEVIO – FAST ACCESS COLORECTAL CLINIC

GP REFERRAL FORM

Purpose: Rapid specialist colorectal assessment for urgent but non-emergency colorectal conditions
Appointment target: Within 3–5 business days of referral receipt

1. Patient Details

Full Name

Date of Birth

Medicare Number

Phone

Interpreter required: Yes No

2. Referring GP Details

GP Name

Practice Name

Provider Number

Phone

Fax / Secure Email

Preferred correspondence Fax Secure Email Medical Objects

3. Reason for Fast Access Referral

(Please tick all that apply)

Anal / Perianal Conditions
Lower GI Symptoms

Rectal bleeding (stable) Change in bowel habit (red flags) Iron deficiency anaemia Rectal pain / tenesmus

4. Symptom Summary

Onset & Duration

Severity / Progression

5. Relevant History

Previous colorectal surgery: Yes No

Previous colonoscopy / sigmoidoscopy: Yes No

Family history of colorectal cancer: Yes No

Significant comorbidities:

6. Examination Findings (if performed)

Perianal findings:

DRE performed: Yes No

Mass / abscess suspected: Yes No

7. Investigations (attach if available)

Blood tests (FBC, iron studies, CRP, etc.) Imaging (US / CT / MRI) Endoscopy reports

8. Urgency Assessment

Fast Access – Stable (suitable for outpatient review) Not suitable – requires ED assessment

Exclusion criteria (please do NOT refer to FAC if present): :

Haemodynamic instability
Ongoing heavy GI bleeding
Sepsis / systemic infection
Acute abdomen
Severe uncontrolled pain requiring IV analgesia

9. GP Declaration

I confirm this patient is clinically stable and appropriate for Fast Access assessment.

GP Signature

Date

10. Submission Details

Secure Email Fax Healthlink : Elevio – Fast Access Colorectal Clinic

What Elevio Will Do:

Appointment within 3–5 business days
Specialist colorectal assessment
Same-day management plan where possible
GP correspondence within 24–48 hours

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