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Easy Access Colonoscopy
Patient Information Form
Colonoscopy Recall
Patient Information Form
personal details
Required Field
*
Dr/Mr/Ms/Miss/Mrs
*
First name
*
Surname
*
Date of Birth
*
Email
Phone Number
*
Address
*
Medicare And Private Health Details
Medicare:
*
Reference:
*
Expiry:
*
Health Care or Pension Card:
Expiry:
Dept of Veteran's Affairs Card:
Healthfund:
Number:
Do you have private hospital cover?
*
Yes
No
Have you been in the fund for 12 months
Yes
No
GP Details
GP Name
*
Practice Name
*
Address
*
Next of Kin
Name
*
Relationship
Phone
*
Covid Vaccination Status
Triple
Double
Single
No Vaccination
reason for referral
Symptoms
Positive Faecal Occult Test
National Bowel Cancer Screening Program
Family History
Single first degree relative diagnosed with colorectal cancer under the age of 50
More than one relative with colorectal cancer
Past history of colorectal polyps where most recent colonoscopy is over 3 years
A past history of colorectal cancer over 5 years ago where most recent colonoscopy is over 3 years
Patient health assessment
Is there a possibility you may be pregnant?
*
Yes
No
Height(m):
*
Weight(kg):
*
Symptoms
Rectal Bleeding
*
Yes
No
Unexplained change in bowel habit
*
Yes
No
Abdominal Pain
*
Yes
No
Unexplained Weight loss
*
Yes
No
Faecal Incontinence
*
Yes
No
Current Medical Conditions
Diabetes
*
Yes
No
Cardiac Stents
*
Yes
No
Severe Heart Disease
*
Yes
No
Mental Illness
*
Yes
No
Dementia
*
Yes
No
Allergies
*
Yes
No
Medications
Do you take blood thinning medications?
(Clopidogrel, Dabiatran, Rivaroxaban, Apixaban, Aspirin, Warfarin)
*
If yes above please state reason for blood thinning medication
Yes
No
Do you take any other prescription, non prescription or alternative medicines?
*
Yes
No
Do you take any diabetic medications?
*
Yes
No
Financial Consent
*
I understand that medical expenses (including any gap payments) incurred as a result of consultation or surgical procedure with my Doctor at the Colorectal Surgery are my responsibility. If requested, I will pay my account in full and take full responsibility for claiming costs from the appropriate private health fund. All accounts are payable within 30 days of receipt. If it becomes necessary to use a Debt collection agency to recover monies owed by the undersigned, charges associated with said collection are also the responsibility of the undersigned. Please check with reception staff to confirm the procedures costs of gap payments that may be incurred.
Privacy Policy
*
Information about your medical and family health history is needed to provide adequate medical diagnoses and appropriate treatment. Medical care requires that each member of your medical team have full knowledge of your health information. To ensure the quality and continuity of your health care, your health information may be communicated via email and other forms of communication to/from health care providers and required recipients. For billing and medical rebate purposes information is provided to account administrators including Medicare, private health funds, hospitals, anaesthetists and assistant surgeons. This practice will at all times endeavour to protect your privacy in compliance with privacy legislation and our privacy policy (available on request).
Consent
*
I give my consent to my Doctor at the Colorectal Surgery and staff to collect, use and disclose my personal health information (via email and other forms of communication) for the purpose of providing the highest quality and continuity of health care in the expectation that this will be implemented as far as practicable in accordance with the privacy legislation and the privacy policy of this practice. In order to arrange operations, tests, or other medical appointments, we need to provide information to other health care providers.
Consultation fees (full payment required on the day unless arrangements made otherwise) this varies depending on Doctor and GAP for procedures.
Please initial to confirm that you accept responsibility for full payment
*
please attach referral Below
Which doctor is your referral for
Dr Peter Hewett
Dr Andrew Luck
Dr Darren Tonkin
Dr Elizabeth Murphy
Dr Christopher McDonald
Dr Chris Lauder
My referral is coming directly from my GP/Specialists rooms
Submit
