Appointment Request Please note: items marked * indicate mandatory fields. Complete this online form to book a “No-Gap” colonoscopy in a private hospital (if you have both medicare and private health insurance). Personal Detail Title - Select -MrMrsMissMsDr First name Last name Preferred name Gender - Select -MaleFemale Date of Birth Please enter date using the format DD/MM/YYYY Contact Details Address Suburb State - Select -ACTNSWNTQLDSATASVICWA Postcode Email Home Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Work Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Mobile Phone Please enter your full mobile number. No spaces please. eg. 0412345678 Preferred Contact Method - Select -EmailHome PhoneWork PhoneMobile Phone Memberships Medicare Number 10 Digits Medicare IRN 1 digit next to cardholder's name Medicare Expiry Date Please enter "Valid To" date - using the format MM/YYYY Private Health Fund Name Private Health Fund Number Are you a member of the Department of Veterans Affairs (DVA)? Yes No Department of Veterans Affairs (DVA) Member Number DVA Card Level - None -GoldWhite Orange Do you require DVA transport booked for you? Yes No Emergency Contact Partner Name Partner Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Next of kin Name Next of kin Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Relationship to next of kin Medical information Referring Doctor Name Referring Doctor Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Reason for requesting a colonoscopy - Select -Altered Bowel Habit (Diarrhoea or Constipation)Anaemia (Low Iron or Haemoglobin)Family History of Bowel CancerPositive Faecal Occult Blood (FOB) TestPrevious Colorectal CancerPrevious PolypsRectal BleedingStomach (Abdominal) PainUnexplained Weakness or Weight LossOther Do you also require a gastroscopy (performed in the same session) - Select -YesNo Reason for requesting a gastroscopy - None -Abdominal BloatingAnaemia (Low Iron or Haemoglobin)DiarrhoeaFamily History of Gastric Cancer Previous Barrett’s Dysplasia HeartburnPossible Lactose IntolerancePrevious Gastric Inflammation (gastritis)RefluxVomiting BloodOther Are you otherwise healthy with no recent hospital admission with breathing or heart conditions, and are not taking blood thinner Are you otherwise healthy with no recent hospital admission with breathing or heart conditions, and are not taking blood thinners (e.g., warfarin, clexane or dabigatran)? Yes No If you have a health condition that concerns you, please describe below. Appointment Details Preferred appointment date Please enter date using the format DD/MM/YYYY Preferred appointment time - Select -MorningMidday Afternoon Preferred Doctor - Select -First AvailableDr Gary McKayDr Maroof KhanDr Santee SanthanamDr Sebastian RodriguesProf Chris Berney Applicable Hospital Type Private Hospital (Private Health Insurance or DVA) Public Hospital (Medicare) Preferred Private Hospital - Select -Mater PrivateNorth Shore Specialist Day HospitalNorwest PrivateStrathfield PrivateWestmead Private HospitalSt George Private Hospital Preferred Public Hospital - Select -Ryde HospitalWestmead HospitalBankstown Lidcombe HospitalSt George Hospital Informed Consent During colonoscopy a flexible colonoscope is inserted via the anus into the bowel to examine the entire colon for polyps, cancer, infection and inflammation. This is a painless procedure with sedation provided by an anaesthetist. You need to drink a bowel preparation and have only clear fluids 24 hours before (no solid food). Colonoscopy 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. If perforation occurs, it may require abdominal surgery to repair the bowel wall. Care will be taken to avoid this complication. Bleeding can occur after removal of a polyp if you are on blood thinners. Anaesthetic risks are very small and will be discussed with you by your anaesthetist the day of your procedure. If you are also having a gastroscopy, this is a quick and safe procedure, with very little risk. There is a small risk of aspiration or wheeze (bronchospasm), which is reduced by fasting (no liquids) the full 6 hours prior to your procedure. Yes, I consent to the above. Consent to release medical information I give my consent to Colorectal Surgeons Sydney, 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 Colorectal Surgeons Sydney, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement. Yes, I consent to the above. Leave this field blank Banner Image
