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03 9466 8466
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About
Quality Statement
Hand Hygiene
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Flexible Sigmoidoscopy
Colonoscopy
Gastroscopy
Iron Infusion
Patients
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Fees
Feedback
Rights and Responsibilities
GP Information
Contact
03 9466 8466
Home
About
About
Quality Statement
Hand Hygiene
Services
Flexible Sigmoidoscopy
Colonoscopy
Gastroscopy
Iron Infusion
Patients
FAQs
Fees
Feedback
Rights and Responsibilities
GP Information
Contact
Pre - Admission
Online Booking
Booking Request
We’ll contact you
Complete Admissions form
THIS FORM IS FOR NEW APPOINTMENTS ONLY.
IF YOU NEED TO CHANGE OR CANCEL A PRE-EXISTING APPOINTMENT PLEASE CALL US ON
03 9466 8466
Which procedure do you want to book for?
(Required)
Gastroscopy
Colonoscopy
Flexible Sigmoidoscopy
Which day of the week suits you for your procedure?
Monday
Tuesday
Wednesday
Thursday
Friday
Any day of the week
Personal Details
Name
(Required)
First
Last
Age (Years)
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Mobile Number
(Required)
Email
(Required)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
What is your height in CM
(Required)
What is your weight in KG
(Required)
Health Details
Are you Diabetic
Yes
No
Do you have an implanted defibrillator in your chest?
Yes
No
Do you have any severe disability or mobility issues?
Yes
No
Insurance Details
What type of Medicare card do you have?
(Required)
Standard (green)
Reciprocal (light yellow)
Interim (light blue)
No Medicare card
Do you have private health insurance for hospital cover?
(Required)
Yes
No
If you do have private health insurance, which fund are you with and what is your membership number?
(Required)
Please attach your referral
(Required)
Accepted file types: pdf, png, jpg, Max. file size: 10 MB.