Book a gastroscopy & colonoscopy

Please note: questions indicated by * are mandatory fields

Your Title:

MrMsMrsProfOther

Given Name *

Last Name *

Middle Names

Date of Birth*

Telephone (Mobile)*

Email Address *

Residential Address *

Do you have a current GP referral ?*
YesNoNot yet but will get one

Referring GP's name?

Referring GP's practice?

Do you have Medicare?*
YesNo

Medicare Number

Reference Number (number that appears before your name on your medicare card)

Do you have a Department of Veteran Affairs (DVA) card?*
YesNo

Do you have private health insurance?*
YesNo

Health Insurance Name

Health Insurance Number

Select the type of endoscopy procedure you require*
upper endoscopy (also called gastroscopy)colonoscopyboth procedures (upper endoscopy and colonoscopy)

If you have requested a colonoscopy, which of the symptoms below most apply to you?*
Change in bowel habit (eg constipation)Rectal bleeding (e.g. blood after wiping)Positive National Bowel Screening TestUnintentional weight lossAnaemia (low haemoglobin or low iron)Previous removal of polyps from bowelPrevious colon or rectal (bowel) cancerFamily history of colon or rectal cancerStomach (abdominal) pain or bloatingNot Applicable

If you have requested an upper endoscopy (also called a "gastroscopy") which of the symptoms below most apply to you?*
Reflux symtpoms or HeartburnAbdominal BloatingPrevious Gastric UlcersPrevious Helicobactor Pylori infectionAnaemia (low haemoglobin or low iron)Barrett's oesophagusPrevious upper gastrointestinal cancerFamily history of stomach, oesophagus or duodenal cancerOther reason not listedNot Applicable

Preferred hospital for procedure

Holroyd Private HospitalWestmead Private HospitalThe Sydney Private HospitalFirst available

Please select if you are on any of the following blood-thinner medications?
AspirinClexaneCalciparinClopidogrelCoumadinEliquisIscoverPradaxaWarfarinXareltoOther

Please select if you are on any of the following diabetic medications?
DiaforminDiamicronForxigaGlucobayInvokanaJardianceMetforminInsulinOther

Please select if you have any of the following medical conditions?
Cardiac StentCardiac DiseasePrevious Heart AttackKidney FailureLiver ConditionEpilepsyLung Disease

Please also feel free to add any additional comments here.

Consent to release medical information
I give my consent to Endoscopy Online, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Endoscopy Online, or their agents and advisors, as may be requested. This is in line with the National Privacy Act. By selecting the box below you agree to these terms and conditions.

Yes, I have read the relevant information on Direct Access Gastroscopy & Colonoscopy including risks and complications, and consent to the above terms and conditions.*

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