Small>
Please note: questions indicated by * are mandatory fields
Your Title ---select---Dra/ProfProf
Given Name *
Last Name *
Provider Number
Your Specialty ---select---General PractitionerSpecialist DoctorOther
Practice Name*
Practice's preferred method for receiving biopsy results and reports ---select---emailfaxArgus
Practice email
Practice fax*
Patient's title * ---select---MrMsMrsDra/ProfProf
Patient's first name *
Patient's last name *
Patient's date of birth *
Patient's telephone (Mobile)*
Please indicate the reason for requesting a gastroscopy and colonoscopy for your patient?*
Does your patient have Medicare? (select)YesNoUnsure
Does your patient have private health insurance or covered by DVA? (select)YesNoUnsure
Preferred hospital for procedure (select)North Shore Specialist Day HospitalWestmead Private HospitalFirst available
Preferred Surgeon (select)Dr Gary McKayDr Maroof KhanDr Sebastian RodriguesFirst Available
Is your patient taking blood thinners? (select)YesNo
Is your patient taking diabetic medications (select)YesNo
Does your patient have a coronary stent or valve replacement? (select)YesNo
Please add any additional comments that may be relevant