Appointment Request – Gastroscopy

Please note: items marked * indicate mandatory fields.

Complete this online form to book a “No-Gap” gastroscopy in the public hospital (if you have a Medicare card), or in a private hospital (if you have private health insurance or DVA).

Personal Detail
Please enter date using the format DD/MM/YYYY
Contact Details
Please enter phone number with area code included. No spaces please. eg. 0298765432
Please enter phone number with area code included. No spaces please. eg. 0298765432
Please enter your full mobile number. No spaces please. eg. 0412345678
Memberships
10 Digits
1 digit next to cardholder's name
Please enter "Valid To" date - using the format MM/YYYY
Are you a member of the Department of Veterans Affairs (DVA)?
Do you require DVA transport booked for you?
Emergency Contact
Please enter phone number with area code included. No spaces please. eg. 0298765432
Please enter phone number with area code included. No spaces please. eg. 0298765432
Medical information
Please enter phone number with area code included. No spaces please. eg. 0298765432
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)?

Appointment Details
Please enter date using the format DD/MM/YYYY
Applicable Hospital Type
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