www.drganeshsurgery.au - Colonoscopy Recall Form

Colonoscopy Recall Form

You will be sent this form if you are due a Recall, please complete the patient information below and one of our Nurses will contact you to arrange a date for your Colonoscopy.
PLEASE DO NOT COMPLETE IF WE HAVE NOT SENT THIS TO YOU
Personal Details
Name*

First NameLast Name
Date of Birth

MonthDayYear
Phone Number
Address*
Address, Suburb, State, Postcode
Email Address*
example@example.com
Medicare And Private Health Details
Medicare
Reference
Expiry
Health Care or Pension Card
Expiry
Dept of Veteran's Affairs Card
Healthfund:
Number
Do you STILL have private hospital cover*

YesNo
GP Details
GP Name
Practice Name
Address
Address, Suburb, State, Postcode
Next Of Kin
Name
Relationship
Phone Number
Covid Vaccination Status
TripleDoubleSingleNo Vaccination
Patient Health Assessment
Have there been any major health issues since you last colonoscopy?*

YesNo
If yes above then please list*
Height(m)
Weight(kg)
Is there a possibility you may be pregnant?*

YesNo
Any Current Symptoms
Rectal Bleeding*

YesNo
Unexplained change in bowel habit*

YesNo
Abdominal Pain*

YesNo
Unexplained Weight loss*

YesNo
Faecal Incontinence*

YesNo
Current Medical Conditions
Diabetes*

YesNo
If "Yes" Please Explain*
Cardiac Stents*

YesNo
If "Yes" Please Explain*
Severe Heart Disease*

YesNo
If "Yes" Please Explain*
Mental Illness*

YesNo
If "Yes" Please Explain*
Dementia*

YesNo
If "Yes" Please Explain*
Allergies*

YesNo
If "Yes" Please Explain*
Medications
Do you take blood thinning medications? (Clopidogrel, Dabiatran, Rivaroxaban, Apixaban, Aspirin, Warfarin)*

YesNo
If yes above please state reason for blood thinning medication*
Do you take any other prescription, non prescription or alternative medicines?*

YesNo
Do you take any diabetic medications?*

YesNo
Financial Consent
*

I understand that medical expenses (including any gap payments) incurred as a result of consultation or surgical procedure with Dr. Shanthan Ganesh are my responsibility. If requested, I will pay my account in full and take full responsibility for claiming costs from the appropriate private health fund. All accounts are payable within 30 days of receipt. If it becomes necessary to use a Debt collection agency to recover monies owed by the undersigned, charges associated with said collection are also the responsibility of the undersigned. Please check with reception staff to confirm the procedures costs of gap payments that may be incurred.
Consent
*

I give my consent to Dr, Shanthan Ganesh and staff to collect, use and disclose my personal health information (via email and other forms of communication) for the purpose of providing the highest quality and continuity of health care in the expectation that this will be implemented as far as practicable in accordance with the privacy legislation and the privacy policy of this practice. In order to arrange operations, tests, or other medical appointments, we need to provide information to other health care providers
Consultation fees (full payment required on the day unless arrangements made otherwise) this varies depending on Doctor and GAP for procedures.
Privacy Consent
*

I consent for Dr. Shanthan Ganesh's rooms to pass on any information in the interest of my health care.
Please Attach Referral Below
File Attachment

Cancelof
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Colonoscopy Recall Form

PLEASE DO NOT COMPLETE IF WE HAVE NOT SENT THIS TO YOU

Personal Details

Medicare And Private Health Details

GP Details

Next Of Kin

Covid Vaccination Status

Patient Health Assessment

Any Current Symptoms

Current Medical Conditions

Medications

Financial Consent

Consent

Privacy Consent

Please Attach Referral Below