Please note: questions indicated by * are mandatory fields

Title

Given Name *

Last Name *

Middle Names

Telephone (Mobile)*

Email Address *

Residential Address

Do you have a current GP referral ?

GP’s name

GP’s phone number or practice details

Do you have Medicare?*

Medicare Number

Do you have private health insurance?*

Do you have DVA?

Health Insurance Name & Number

Preferred consultation location

Preferred Surgeon

Please briefly state the nature of your consultation *


Consent to release medical information *

I give my consent to Endoscopy Online, 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 consent to the terms above

[bwsgooglecaptcha bwsgooglecaptcha-567]