RAPID ACCESS ENDOSCOPY | REFERRAL FORM

ELIGIBILTY

Rapid Access Endoscopy provides eligible patients with appropriate indications to undergo gastroscopy and / or colonoscopy at a private hospital without the need to wait for a consultation prior. Patients will need to have valid private health insurance, DVA card or wishes to self-fund the procedure.

Generally fit and healthy
Under 80 years of age
No history of serious heart, lung, kidney, liver disease
Not on anticoagulation
Well-controlled diabetes (not on SGLT2i or insulin)

Please complete the form OR send referral letter and indicate "RAPID ACCESS" to:

EMAIL: endoscopy@drhenrycheung.com.au | FAX: (02) 9480 8555

SERVICES REQUESTED

CHOOSE ALL APPLICABLE *

GastroscopyColonoscopyConsultation First

INDICATIONS

Please select one or more of the following: *

Positive FOBTChange in bowel habitsIron deficiencyWeight lossReflux / DyspepsiaFamily HistorySurveillanceOthers

If "others", please specify:

PATIENT DETAILS

NAME *

DOB *

ADDRESS *

MOBILE *

EMAIL *

MEDICARE (Including Ref. No.) *

EXP DATE *

DOES THE PATIENT HAVE PRIVATE HEALTH COVER? *

YesNo

NOTE: Those without private health cover is not eligible for Rapid Access Endoscopy unless they wish to self fund the procedure

PRIVATE HEALTH FUND

MEMBERSHIP NUMBER

PATIENT’S MEDICAL BACKGROUND

Heart Disease

Lung Disease

Diabetes

Is the patient on SGLT2i or Insulin? (If 'Yes", please provide details) *

HbA1c

Renal Impairment

Liver Disease / Cirrhosis

Others

Please specify

ATTACHMENT(S)

Referral Letter

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Additional Medical History or other information

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