PATIENT DETAILS	

Name:	Patient Demographics.Full Name	D.O.B.:	Patient Demographics.DOB	

Phone (Mobile):	Patient Demographics.Phone (Mobile)	(Home):	Patient Demographics.Phone (Home)	

Medicare Number:	Patient Demographics.Medicare Number	Expiry:	Patient Demographics.Medicare Expiry Date			
Reciprocal Medicare Card holders will incur additional fees.	

Address:
	Patient Demographics.Full Address	

REFERRAL/APPOINTMENT DETAILS	

Location preference:			Sydenham			Werribee			ANY				

Appointment type			Consultation			Gastroscopy			Colonoscopy			Colonoscopy + Gastroscopy	

			Capsule endoscopy (pill cam)			Flexible Sigmoidoscopy
	
			Other (please specify):			Preferred Specialist (optional)	

Does the patient require extended bowel preparation (eg. chronic constipation, unsatisfactory prep in past)?			No			Yes		
Reason for referral:

	
Please provide date/results of most recent colonoscopy if applicable:	
If iron deficiency/anaemia, please provide:     1. Haemoglobin:                                                   2. Ferritin:	
MEDICAL HISTORY    Please attach Patient Health Summary (if possible)	
Diabetes:			No			Yes			Type 1			Type 2	Current treatment:		
Respiratory conditions:			No			Yes	Details: (please inc Sleep Apnoea if present)		
Cardiac history:			No			Yes	Details:		
Hospitalised in last 6 months:			No			Yes	Details:		
Height:	Current Measurements.Physical - Height	Weight:	Current Measurements.Physical - Weight	BMI:		Our policy is a maximum BMI of 45 for all endoscopic procedures.		
MEDICATIONS	
Anticoagulants or antiplatelets:			No			Yes	Details:		
Current medications:			No			Yes	Details:		
	
Allergies:	
REFERRER INFORMATION	
Name: Treating Doctor.Name	
Practice: Treating Doctor.ABN/Business Name	Location:Treating Doctor.Full Address		
Phone: Treating Doctor.Phone	Provider number: Treating Doctor.Provider Number		
Signature:
	Date: Miscellaneous.Date	
	
Please advise all patients who are having a procedure that they will need someone to drive them home and stay with them overnight.	
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PATIENT INFORMATION
________________________________	Hobson Healthcare 
Endoscopy + Day Surgery		Hobson		Healthcare	1800446276			

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			

	SYDENHAM	WERRIBEE	

	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	

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