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Please note: questions indicated by * are mandatory fields
Preferred mode to receive tele-health call?* (select)regular call (mobile)regular call (landline)ZoomKakao TalkSkypeViberWhatsApp
Preferred mode to receive tele-health call?*
Given Name *
Given Name
Last Name *
Last Name
Telephone Number*
Telephone Number
Your email address *
Your email address
Do you have a current GP referral ? * (select)YesNoWork in Progress
Do you have a current GP referral ? *
GP’s name
GP’s provider number
GP’s practice name or location
Do you have Medicare?* (select)YesNo
Do you have Medicare?*
Medicare Number
Please briefly state the nature of your consultation *
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 consent to the terms above