Which procedure do you want to book for? * GastroscopyColonoscopyGastroscopy AND ColonoscopyLiver Fibosis Scan
Which Centre would you like to book for? If you are happy to travel, please select more than one facility * Rosebud Day Hospital (Rosebud)Casey Day Procedure Centre (Narre Warren)Knox Day Hospital (Bayswater)Hampton Day Hospital (Hampton East)Bayside Day Procedure Centre (Frankston)
FIRST NAME *
SURNAME *
AGE (Years) *
DATE OF BIRTH *
HOME ADDRESS *
MOBILE NUMBER *
Are you Diabetic? * YesNo
What is your height in CM *
What is your weight in KG * (Please note-if your weight is 130kg or more, please call us on 9781 5959)
Do you have an implanted defibrillator in your chest? * (Please note- if you have a defibrillator, please call us 9781 5959) YesNo
Do you have any severe disability or mobility issues? * YesNo
What type of Medicare card do you have? * Please tick Standard (green)Reciprocal (light yellow)Interim (light blue)No Medicare card
Do you have private health insurance for hospital cover? * YesNo
If you do have private health insurance, which fund are you with and what is your membership number?
Which day of the week suits you for your procedure? Please note that the liver fibrosis scans are only booked for Fridays and some Day Hospital Centres only operate on certain days. You will need a friend/relative to drive you to and from this appointment * MondayTuesdayWednesdayThursdayFridayAny day of the week
YOU WILL BE SENT AN SMS OF AN APPOINTMENT DATE, TIME AND LOCATION WITHIN 2-3 BUSINESS DAYS,
IF THIS DATE DOES NOT SUIT YOU PLEASE CONTACT US ON 9781 5959 .
Please note- If you are pregnant, you cannot undergo any anaesthetic or sedation related procedure at Direct Endoscopy. Please speak to your GP.
