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Appointment Request – Gastroscopy

Please note: items marked * indicate mandatory fields.

Complete this online form to book a “No-Gap” gastroscopy in a private hospital (if you have both Medicare and private health insurance).

Personal Detail

Title

First name

Last name

Preferred name

Gender

Date of Birth

Please enter date using the format DD/MM/YYYY

Contact Details

Address

Suburb

State

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

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

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 gastroscopy

Do you also require a colonoscopy (performed in the same session)

Reason for requesting a colonoscopy

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

Preferred Doctor

Applicable Hospital Type

Private Hospital (Private Health Insurance or DVA)

Public Hospital (Medicare)

Preferred Private Hospital

Preferred Public Hospital

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 difficulties similar to asthma immediately 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 is very much related to your previous medical conditions, and this will be discussed with you by your anaesthetist the day of 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

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