Please note: questions indicated by * are mandatory fields

Your Title:
 Mr Ms Mrs Prof Other

Given Name *

Last Name *

Middle Names

Date of Birth*

Telephone (Mobile)*

Email Address *

Residential Address *

Do you have a current GP referral ?*
 Yes No Not yet but will get one

You can upload your GP referral now or bring it with you on the day.

Referring GP's name?

Referring GP's practice?

Do you have Medicare?*
 Yes No

Medicare Number

Reference Number (number that appears before your name on your medicare card)

Do you have a Department of Veteran Affairs (DVA) card?*
 Yes No

Do you have private health insurance?*
 Yes No

Health Insurance Name

Health Insurance Number

What is the reason for having the gastroscopy?*
 Reflux symtpoms or Heartburn Abdominal Bloating Previous Gastric Ulcers Previous Helicobactor Pylori Infection Anaemia (low haemoglobin or low iron) Barrett's Oesophagus Previous Upper Gastrointestinal Cancer Family history of stomach, oesophagus or duodenal cancer Stomach (Abdominal) Pain or Bloating Other

Preferred date for procedure (Monday to Friday only)

Preferred hospital for procedure
 North Shore Specialist Day Hospital Westmead Private Hospital First available

Preferred Surgeon
 Dr Barry McCabe Dr Maroof Khan Dr Sebastian Rodrigues First Available

Please select if you are on any of the following blood-thinner medications?
 Aspirin Clexane Calciparin Clopidogrel Coumadin Eliquis Iscover Pradaxa Warfarin Xarelto Other

Please select if you are on any of the following diabetic medications?
 Diaformin Diamicron Forxiga Glucobay Invokana Jardiance Metformin Insulin Other

Please select if you have any of the following medical conditions?
 Cardiac Stent Cardiac Disease Previous Heart Attack Kidney Failure Liver Condition Epilepsy Lung Disease

Please also feel free to add any additional comments here.

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 have read and consent to the above terms and conditions. *

Yes, I have read the relevant information on Direct Access Gastroscopy including risks and complications.*

[bwsgooglecaptcha bwsgooglecaptcha-42]