PATIENT DETAILS	
Name:	<PtFullName>		D.O.B.:	<PtDoB>	
Phone (Mobile):	<PtPhoneMob>	(Home):	<PtPhoneH>	
Medicare number:	<PtMCNo>	Expiry: <PtMCExpiry>	Number on Card:	<PtMCLine>	
Reciprocal Medicare Card holders will incur additional fees.	
Address:	<PtAddress>	

REFERRAL/APPOINTMENT DETAILS	
<Location preference:>Location preference:	<Altona> Altona	<Sydenham> Sydenham	<Werribee> Werribee	<ANY> ANY	
<Appointment type:>Appointment type:	<Consultation> Consultation	<Gastroscopy> Gastroscopy	<Colonoscopy> Colonoscopy	<Colonoscopy + Gastroscopy> Colonoscopy + Gastroscopy	
	<Capsule endoscopy (pill cam)> Capsule endoscopy (pill cam)	<Flexible Sigmoidoscopy> Flexible Sigmoidoscopy	
	<Other (please specify)> Other (please specify): <Other appointment type:>	<Preferred Specialist (optional)> Preferred Specialist (optional)	
Does the patient require extended bowel preparation (e.g., chronic constipation, unsatisfactory prep in past)?	<Does the patient require extended bowel preparation (e.g., chronic constipation, unsatisfactory prep in past)?>	
<What is the reason for referral> Reason for referral: <Reason for referral:>	
	
Please provide date/results of most recent colonoscopy if applicable:	<Please provide date/results of most recent colonoscopy if applicable:>	
<If iron deficiency/anaemia, please provide:> If iron deficiency/anaemia, please provide:	1. Haemoglobin: <Haemoglobin:>	2. Ferritin: <Ferritin:>	

<Medical history:> MEDICAL HISTORY  Please attach Patient Health Summary (if possible)	
Diabetes:	<Does the patient have diabetes?>	  <Diabetes Type 1> Type 1 <Diabetes Type 2> Type 2	Current treatment: <Diabetes current treatment:>	
Respiratory conditions:	<Does the patient have respiratory conditions?>	Details: (please incl. Sleep Apnoea if present) <Respiratory conditions details:>	
Cardiac history:	<Does the patient have cardiac history?>	Details: <Cardiac history details:>	
Hospitalised in last 6 months:	<Has the patient been hospitalised in last 6 months?>	Details: <Hospitalisation details:>	
Height: <Patient height:>
Weight: <Patient weight:>	BMI: <Patient BMI:>	Our policy is a maximum BMI of 45 for all endoscopic procedures.	

MEDICATIONS	
Anticoagulants or antiplatelets:	<Anticoagulants or antiplatelets?>	Details: <Details for anticoagulants or antiplatelets:>	
Current medications:	<Current medications?>	Details: <Details for current medications:>	
			
Allergies:	<Patient allergies:>	

REFERRER INFORMATION	
Name:	<DrName>			
Practice:	<Practice>	Location:	<UsrAddress>	
Phone:	<DrPhone>	Provider number: 	<DrProviderNo>	
Signature:		Date:	<TodaysDate>	
Please advise all patients who are having a procedure that they will need someone to drive them home and stay with them overnight.	

	
Your doctor has asked that you make an appointment to see us.
Please email this form to: hobson.bookings@healthEcare.com.au	

Preparation
We will provide you with instructions regarding diet, fasting and laxative preparation (for colonoscopy) when you make your appointment.	Appointment time
This is your arrival time, NOT your procedure time. We will endeavour to perform your procedure as soon as possible after arrival.		
Medications
Please advise us if you are taking Warfarin, Aspirin or Diabetic Medication. We will provide instructions.	What happens after the procedure?
You will awaken in the recovery area and will be provided a light refreshment before going home.		
Travel
You must arrange for an adult to drive you home.
You must not drive for the remainder of the day after your test. If you live alone, you have someone stay with you overnight.	Any questions?
If you have any questions, please do not hesitate to call, or visit your nearest Hobson Healthcare centred listed.		

Centre and specialist	
ALTONA	SYDENHAM	WERRIBEE	
•	Dr Nj Arachchi
•	Dr Chamara Basnayake
•	Dr Ramez Bassari
•	Dr Jal Bhathawalla
•	Mr Hai Bui
•	Dr Andrius Kalade
•	Dr Mark Lust
•	A/Prof Ashley Miller
•	A/Prof Peter Nottle
•	Dr Saam Tourani
•	Dr Johnathan Tan
•	Dr Shiran Wijeratne
•	Mr Jason Winnett
•	Dr Simon Zanati	Endoscopy
• Dr Nj Arachchi
• Dr Georgina Baker
• Dr Robert Chen
• Dr David Iser
• A/Prof Ashley Miller
• Dr Johnathan Tan
• Dr Thai Hong
Endoscopy + Surgical
• Mr Ramez Bassari
• Dr Jal Bhathawalla
• Mr Hai Bui
• Mr Matthew Croxford
• Mr Chris Lu
• A/Prof Peter Nottle
• Mr Jason Winnett
• Mr Satish Warrier	Oral + Maxillofacial
• A/Prof Arun Chandu
• Mr Felix Sim
• Mr Graeme Wright
Dental
• Dr Nasr Bachawaty
• Dr Anuj Batra
• Dr Kar Man Chan
• Dr Bill Crawford
• Dr Andrew Maimur
• Dr Deb Wong
• Dr Rana Yarwary
Urology
• Mr Andrew Troy	• Dr Niranjan Arachchi
• Mr Yahya Al-Habbal
• Dr Georgina Baker
• Dr Ramez Bassari
• Dr Hai Bui
• Dr Elliot Freeman
• Dr Michael Hong
• Dr Andrius Kalade
• Dr Mark Lust
• Dr Dileep Mangira
• A/Prof Ashley Miller
• A/Prof Peter Nottle
• Mr. Mohammad Rafique	• Mr Iain Skinner
• Dr. Saam Tourani
• Mr Jason Winnett
• Dr Audrey Yeo	

Contact us	
			
Cnr Queen & Sargood St Altona 3018
P. 1800 446 276 F. 03 9398 8822
atn.admin@healthEcare.com.au
hobsonhealthcare.com.au	566 Melton Hwy Sydenham 3037
P. 1800 446 276 F. 03 8361 6700
sdh.admin@healthEcare.com.au
hobsonhealthcare.com.au	179 Princes Hwy Werribee 3030
P. 1800 446 276 F. 03 9731 8001
wbe.admin@healthEcare.com.au
hobsonhealthcare.com.au