Easy Access Colonoscopy Form | Colorectal Surgery | Colorectal and General Surgery

08 8267 3355 142 Ward Street, North Adelaide Mon - Fri: 9:00am - 5:00pm

easy access colonoscopy form

Personal Details

Title:

First Name:

Surname:

Date of Birth:

Email:

Phone Number:

Address:

Medicare And Private Health Fund Details

Medicare No:

Ref No:

Expiry:

Health Care or Pension Card:

Expiry:

Department of Veteran's Affairs:

Expiry:

Private Hospital Fund:

Membership No:

Do you have private hospital cover?

Yes

Have you been in the fund for 12 months?

Yes

GP Details

GP Name:

Practice Name:

Address:

Next of Kin

Name:

Relationship:

Phone:

Covid Vaccination Status

No Vaccination

Single

Double

Triple

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

Height (cm):

Weight (kg):

Symptoms

Current Medical Conditions

Medications

Do you take blood thinning medications?
(Clopidogrel, Dabiatran, Rivaroxaban, Apixaban, Aspirin, Warfarin)

Yes

If yes above please state reason for blood thinning medication

Do you take any other prescription, non prescription or alternative medicines?

Yes

Do you take any diabetic medications?

Yes

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 attach referral Below

My referral is coming directly from my GP/Specialists rooms