Endoscopy Connect

Endoscopy Connect

GET IN TOUCH

Send us a message

CONTACT US

Home
About Us
Procedures
For Doctors
For Patients
- +FOBT
Fees
Contact Us

BOOK A PROCEDURE

Patient Information

Patient Information

Endoscopy Direct

Patient Information

Patient Details

PATIENT DETAILS

Personal Title*

Miss

Ms

Mrs

Mr

Dr

First Name*

Surname*

Date of Birth*

Address*

Suburb*

State*

Postcode*

Mobile*

Home Phone

Work

Email*

Medicare No.*

Ref No.*

Valid to*

Health Fund Name

Member No.

Pension Card No.

Exp Date

Name of referring GP*

Suburb*

Phone*

Free Text

PROCEDURE

Procedure

Colonoscopy

Gastroscopy

Capsule endoscopy (Pillcam)

Free Text

HEALTH INFORMATION

Your height (cm)?*

Your weight (kg)?*

Do you take prescription medications?*

Yes

No

Free Text

Have you had major surgery of the brain, heart, abdomen, or pelvis?*

Yes

No

New Field:

Have you had a diagnosis of major illness or disease of the brain, heart, lungs, liver, or kidneys?*

Yes

No

if YES, please list procedures and illness with dates

Can you walk unaided up two flights of stairs without resting or stopping?*

Yes

No

Have you had a previous endoscopy, gastroscopy, colonoscopy?*

Yes

No

If yes, please provide: when and where you had the procedures & the Doctor who performed the procedure.

DISCLAIMER:

I acknowledge that as a patient of Endoscopy Connect (in association with SEG Specialist Services Pty Ltd), a medical record containing personal information will be maintained throughout your treatment. During the period of assessment and ongoing management, information of relevance is recorded in clinical notes. These records will be stored securely and may be kept up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances there may be a legal obligation to disclose clinical information.

For Medicare Card Holders: I hereby give permission for Endoscopy Connect (in association with SEG Specialist Services Pty Ltd) to use Medicare Online Claiming and/or online electronic account transmission on my behalf when required, and I assign my right to Medicare benefits to the Practitioner who rendered the service/s.

For NON-Medicare-Card Holders: I acknowledge that there will be an out-of-pocket fee for any services provided it is my responsibility to confirm with my insurance (if any) if I am able to claim.

Thank you for completing this questionnaire.

The Endoscopy Connect Liaison Nurse will call you within the next 2 working days

Oops, there was an error sending your message.
Please try again later

PHONE

HEAD OFFICE

Level 1, 451 New South Head Road Double Bay, NSW 2028

EMAIL

Send us a message

Services

Colonoscopy
Gastroscopy/Endoscopy
Capsule Endoscopy / Pillcam

Endoscopy Direct can save a life by providing timely, flexible and affordable access to high quality endoscopic services for diagnosis and treatment.

Opening Hours

Monday to Friday

Share by: