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Please note: questions indicated by * are mandatory fields

Your Title:
 Mr Ms Mrs Prof Other

Given Name *

Last Name *

Middle Names

Date of Birth*

Telephone (Mobile)*

Email Address *

Residential Address *

Do you have a current GP referral ?*
 Yes No Not yet but will get one

You can upload your GP referral or other relevant clinical results now.

Referring GP's name?

Referring GP's practice?

Current treating specialist's name?

Current treating specialist's practice name or location?

Do you have Medicare?*
 Yes No

Medicare Number

Reference Number (number that appears before your name on your medicare card)

Do you have a Department of Veteran Affairs (DVA) card?*
 Yes No

Do you have private health insurance?*
 Yes No

Health Insurance Name

Health Insurance Number

What is the reason for requesting a second opinion?*
 unhappy with current treatment/decision Would ideally like transfer of care Obtaining information to ensure best possible outcome Other

Preferred Surgeon to provide second opinion
 Dr Barry McCabe Dr Maroof Khan Dr Sebastian Rodrigues First Available

Please describe in detail the nature of your request for a second opinion

Consent to release medical information
In order to obtain a second opinion, I give my consent to Endoscopy Online (Colorectal Surgeons Sydney), or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Endoscopy Online, or their agents and advisors, as may be requested. This is in line with the National Privacy Act. By selecting the box below you agree to these terms and conditions.

Yes, I have read and consent to the above terms and conditions. *

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