Book A Gastroscopy Online

Complete this online form to book a gastroscopy.

Reason for requesting a gastroscopy*

Select your type of Health Cover*

Are you otherwise healthy with no recent hospital admission with breathing or heart conditions, and are not taking blood thinners (eg, warfarin, clexane or dabigatran) ? *

If you have a health condition that concerns you please describe below.

 yes no

Title *

First Name*





Contact Phone Number*


Medicare Number

Medicare Family Reference Number

Health Fund

Health Fund Membership Number (if applicable)

Preferred Private Hospital for Gastroscopy (if have private health insurance or DVA)

Preferred Public Hospital for Gastroscopy (if have medicare only)

Preferred Surgeon

If Colonoscopy is also required select your reason


Informed Consent

Gastroscopy is performed using a flexible gastroscope which is inserted under sedation. This sedation is provided by an anaesthetist. Gastroscopy allows the surgeon to examine the food tube connecting the mouth to the stomach (oesophagus), the stomach and the first part of the small bowel (i.e. duodenum) to exclude reflux, inflammation (gastritis) and conditions that cause diarrhoea (coeliac disease, lactose intolerance). It can also exclude ulcers, polyps and cancer. This is a quick, painless and safe procedure with few complications. A rare complication is wheezing or breathing difficulites similar to asthma immedicately after the procedure. If this occurs, it can be managed by your anaesthetist. If you also require a colonoscopy, it will require a bowel preparation to clean the colon. Drinking plenty of fluids the day before colonoscopy is important to prevent dehydration. Colonoscopy is a short procedure that is extremely safe, however all procedures have some risk. Perforation of the colon is a complication where a hole is made in the bowel. It is rare and occurs in less than 0.2% of cases. The risk of perforation following colonoscopy where a polypectomy is also performed is 0.3-1.0%. If perforation occurs, it usually requires abdominal surgery to close the defect in the bowel wall. Care will be taken to avoid this complication. Occasionally bleeding can occur particularly if a polyp has been removed. The risk of anaesthetic are very much related to your previous medical conditions, and this will be discussed with you by your anaesthetist the day of your procedure.


Have you read the above “Informed Consent” for gastroscopy and agree to go ahead with gastroscopy? *

 yes no

Referring GP's Name *

Referring GP's Phone Number *

Have you answered 'yes' to all of the above questions qualifying you to have a gastroscopy booked online?*

 yes no

Please type the letters and numbers above.

select here for a Video Description of Gastroscopy.

select here for a Detailed Description of Gastroscopy.