Referral for Intestinal Ultrasound - Eastern Health Patients

Eastern Health UR Number *

Patient First Name *

Patient Last Name *

Date of Birth (dd/mm/yyyy) *

Gender

MaleFemaleIntersex

Street

Suburb

State

Postcode

Contact Phone *

Email Address

Indication/Clinical Details

Indication for Intestinal Ultrasound (Tick all that apply) *

Crohn's DiseaseUlcerative ColitisNon-IBD / Other (Specify Symptoms)

Clinical Notes/ Comments

Ulcerative Colitis

ProctitisLeft-sided colitisExtensive colitis

Previous Bowel Surgery?

NoYes (Specify)

IBD Medications

NilSulfasalazine / MesalazineAzathioprine / 6MP / MethotrexateTofacitinib / Upadacitinib

IBD Medications Cont.

Infliximab / AdalimumabVedolizumabUstekinumabOther (Specify)

Priority

Urgent (< 1 month)Next Avail / Unspecified

Specify Time Frame

Name of Referring Doctor *

Provider No. *

Referrer's Phone *

GP (if different to referrer)