Direct Access Endoscopy Referral Please fill out the online form below Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.PATIENT DETAILS For suitable patients (without prior specialist consultation)Full Name *DOB *Contact Number *Email *Address *Address Line 1Address Line 2City--- Select state ---Please SelectSouth AustraliaWestern AustraliaVictoriaNew South WalesQueenslandTasmaniaAustralia Capital TerritoryNorthern TerritoryState / TerritoryPostalMedicare Number *Private Health FundPrivate Health NumberDepartment of Veterans Affairs (DVA) NumberPROCEDURE REQUESTEDProcedures *GastroscopyColonoscopyGastroscopy and ColonoscopyAllurion Intragastric BalloonREASON FOR PROCEDUREGastroscopyOesophageal refluxDifficulty swallowingBarrett’s surveillanceAbdominal bloatingTest for coeliac disease/lactose intoleranceOtherGastroscopy - If other please describeColonoscopyPositive FOBTPR bleedingFamily history of bowel cancerChanges in bowel functionPrevious polyp or cancerOther Number describe Colonoscopy Colonoscopy - If other please describeMEDICAL HISTORYHistory *Heart DiseaseLiver DiseasePrevious Abdominal SurgeryAllergiesLung DiseaseDiabetesAny Diabetes MedicationKidney DiseaseAny Blood ThinnersOtherMedical History - If other please describeREFERRALDoctor’s Name *- Please SelectDr George BalalisDr Jesse BeumerDoctor’s Practice *Provider Number *PATIENT DETAILS Are under 80 years of age Able and willing to consent in English Are fit and healthy Have a current referral Are not taking anticoagulant or blood thinning medication, aside from aspirin Have no history of heart disease, obesity, diabetes, stroke, epilepsy, kidney or liver disease, or serious lung disease Have somebody to transport them to and from the hospital Have private health insurance or wish to have their colonoscopy in a private hospital Note – if patients do not fulfill these criteria, they will need a consultation with a Morphē surgeon prior to their procedure PROCEDURE Send Direct Access Procedure Formonline, or via email, fax or post Each Referral will be reviewed by a Morphē surgeon to confirm suitability Patients will then be contacted by the practice to arrange a convenient time for the procedure and answer any questions Any patient considered unsuitable for Direct Access will be offered an appointment to see a Morphē surgeon Bowel Preparation Instructions - will be organised on discussion with your surgeon. DAY OF THE PROCEDURE Patients will arrive at the hospital day procedure area The surgeon will meet with the patient to review their history, discuss the procedure and gain informed consent The procedure will be performed, with an anaesthetist administering the sedation The results of the procedure will be discussed with the patient on the day, and a report sent to the referring doctor Submit
Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.PATIENT DETAILS For suitable patients (without prior specialist consultation)Full Name *DOB *Contact Number *Email *Address *Address Line 1Address Line 2City--- Select state ---Please SelectSouth AustraliaWestern AustraliaVictoriaNew South WalesQueenslandTasmaniaAustralia Capital TerritoryNorthern TerritoryState / TerritoryPostalMedicare Number *Private Health FundPrivate Health NumberDepartment of Veterans Affairs (DVA) NumberPROCEDURE REQUESTEDProcedures *GastroscopyColonoscopyGastroscopy and ColonoscopyAllurion Intragastric BalloonREASON FOR PROCEDUREGastroscopyOesophageal refluxDifficulty swallowingBarrett’s surveillanceAbdominal bloatingTest for coeliac disease/lactose intoleranceOtherGastroscopy - If other please describeColonoscopyPositive FOBTPR bleedingFamily history of bowel cancerChanges in bowel functionPrevious polyp or cancerOther Number describe Colonoscopy Colonoscopy - If other please describeMEDICAL HISTORYHistory *Heart DiseaseLiver DiseasePrevious Abdominal SurgeryAllergiesLung DiseaseDiabetesAny Diabetes MedicationKidney DiseaseAny Blood ThinnersOtherMedical History - If other please describeREFERRALDoctor’s Name *- Please SelectDr George BalalisDr Jesse BeumerDoctor’s Practice *Provider Number *PATIENT DETAILS Are under 80 years of age Able and willing to consent in English Are fit and healthy Have a current referral Are not taking anticoagulant or blood thinning medication, aside from aspirin Have no history of heart disease, obesity, diabetes, stroke, epilepsy, kidney or liver disease, or serious lung disease Have somebody to transport them to and from the hospital Have private health insurance or wish to have their colonoscopy in a private hospital Note – if patients do not fulfill these criteria, they will need a consultation with a Morphē surgeon prior to their procedure PROCEDURE Send Direct Access Procedure Formonline, or via email, fax or post Each Referral will be reviewed by a Morphē surgeon to confirm suitability Patients will then be contacted by the practice to arrange a convenient time for the procedure and answer any questions Any patient considered unsuitable for Direct Access will be offered an appointment to see a Morphē surgeon Bowel Preparation Instructions - will be organised on discussion with your surgeon. DAY OF THE PROCEDURE Patients will arrive at the hospital day procedure area The surgeon will meet with the patient to review their history, discuss the procedure and gain informed consent The procedure will be performed, with an anaesthetist administering the sedation The results of the procedure will be discussed with the patient on the day, and a report sent to the referring doctor Submit
