Epworth HealthCare
Pancreatic Cancer
Referral Form

 Patient details	

Name:
UR (if an existing Epworth patient):
Address:

Telephone:	Email:

Postcode:

Gender:	DOB:	/	/

Medicare card number:	Expiry date:	/

Health fund:

Yes

No

Name of fund:

Membership number:

Department of Veteran Affairs:

Gold

White

Membership number:

 Please select your patient's preferred Epworth location/s:	

Epworth Eastern (Box Hill)

Epworth Freemasons (East Melbourne)

Epworth Geelong

Epworth Richmond

 Next of kin details	
Name:

Telephone:	Relationship to patient:

 Referrer details	
Name:	Provider number:

Specialist

GP

Clinic name:

Address:

Telephone:	Fax:
Email:

Postcode:

www.epworth.org.au/jreissaticentre

Epworth HealthCare
Pancreatic Cancer
Referral Form

 Reason for referral	

Suspected pancreatic cancer/investigations

Second opinion

Treatment

Clinical trial

Additional information:

 Medical information	
Imaging results:

CT:

EUS:

MRI:

Other:

Please attach any relevant correspondence, imaging, histology or pathology results with this referral. Details of relevant past medical history, current medications and allergies:

Other additional information:

Sign here:

Signature:	Date:	/	/

Please email your referral form to our pancreatic nurse coordinator at EHJreissatiCentre@epworth.org.au

Jreissati Family Pancreatic Centre at Epworth
Suite G4, 173 Lennox Street, Richmond VIC 3121 Phone 03 9426 8880
Email  EHJreissatiCentre@epworth.org.au

www.epworth.org.au/jreissaticentre