• Dr Krishan Pratap - Referral and Patient Information Form

    River City Gastroenterology | 07 3063 1273 | admin@rivercitygastro.com.au

  • Completing these questions can take about 5 minutes to 30 minutes, depending on your medical history.

    Please note that you can save your progress on this form at any point by clicking the "Save" button at the bottom of the page.

    If you need to step away or gather additional information, simply save your work and close the form. You can easily continue where you left off by clicking the unique link that will be sent to your email address that enter on the first page of the form.

    This link will remain active, allowing you to complete the form at your convenience.

    If you have any questions or concerns while filling out the form, please don't hesitate to contact our office for assistance.

  • Date of Form Completion
     / /
    2 digit day, 2 digit month, 4 digit year

  • Patient Details

  • Date of Birth*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Gender*
  • Are you of Aboriginal or Torres Straighter Islander origin?
  • Home Address*
  • Format: 0000 000 000.
  • Format: 00 0000 0000.
  • Do you have an Email Address?*
  • Do you have a Next of Kin / Emergency Contact person?*

  • Next of Kin / Emergency Contact Details

  • Relationship to you*
  • Format: 0000 000 000.
  • Do you consent to us discussing your care/results with your next of Next of Kin / Emergency Contact person?*

  • Medicare and Health Insurance Information

    Remember, you can save your progress at any time and complete this form later using the link sent to your email.
  • Do you have a Medicare card?*

  • Important Information about Outpatient Consult Appointments

    The full cost of the outpatient consult appointment is payable in full at the time of the appointment.

    If you are eligible for a Medicare rebate (hold a valid Medicare card), your claim will be processed on your behalf. You can expect your Medicare rebate within 2 days of your invoice being processed.

    If you are not eligible for Medicare, you will not receive any rebate.  If you have a policy with an overseas insurer, we can issue you with a receipt for you to claim directly from your insurer.

  • Do you have a DVA card?
  • What DVA card do you have?*
  • Do you have Private Health (hospital) Insurance?*

  • Important Information for Patients Without Private Health Insurance

    If you do not have private health insurance, you will be required to pay the full cost of any in-hospital procedure.

    We encourage you to review the expected costs and consider your payment options before scheduling a procedure.

    You will be provided a quote for the estimated costs at the time of scheduling the admission/procedure.

  • Important Information About Private Health Insurance Coverage

    If you require an in-hospital procedure or admission, it is your responsibility to contact your private health insurer to confirm you are covered for any treatment.

    You will be provided a quote for the estimated surgeon's costs (if applicable) at the time of scheduling the admission/procedure.

  • Important Information About Overseas Insurance Policies

    Please note that if any admissions or surgical procedures are required, the fees for the doctor must be paid in full and up-front. You will be provided with a tax invoice that you can submit to your insurer to receive your entitled rebate.

  • Insurer*
  • Have you held a hospital cover policy (Bronze, Silver, or Gold) for 12 months or more?*

  • Note: If you have held hospital cover for less than 12 months, you may not be covered for any procedures. If so, you will be required to pay the full amount upfront and liaise with your insurer.

  • Referring Doctor or GP

    Remember, you can save your progress at any time and complete this form later using the link sent to your email.
  • Is the Referring Practitioner also your GP?*

  • Supporting Information

    Remember, you can save your progress at any time and complete this form later using the link sent to your email.

  • Referral Required for Medicare Rebates

    To be eligible for Medicare rebates, you must have a valid referral from a GP or specialist. If you proceed without a referral, you will not be able to claim any Medicare rebates and will be responsible for the entire cost of the consultation or procedure.

    If your referring doctor has not sent your referral to us already, you must supply the referral.

    To ensure you are eligible for rebates and to avoid surprises, please ensure you have a valid referral before booking to avoid unexpected out-of-pocket expenses.

  • Do you have a referral to upload?*

  • Referral for Triage by the Doctor

    The Doctor requires a referral from your GP or another specialist to safely and accurately triage your referral.  

    Please obtain a valid referral prior to completing this form.

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  • Have you had any recent scans (for example CT, Ultrasound, X-ray) that relate to this referral?*
  • Where were the scans done?*
  • Have you had any recent blood or pathology tests that relate to this referral?*
  • Where were the blood tests done?*
  • Have you had any other recent tests/scan relevant to this referral?

  • Medical History and Medications

    Remember, you can save your progress at any time and complete this form later using the link sent to your email.

  • It is very important that you carefully list your medical history and medications accurately.

    It may be dangerous if you do not list your medications and the doctors involved in your care do not know about them.

    If you do not list your medications accurately, any scheduled procedures may be cancelled.

  • What is your weight and height?*
  • Do you have any allergies / are you allergic to any medications?*
  • Please select any that apply - Risk factors*
  • Please select any that apply - Other*
  • Please select any that apply - Heart/cardiac disease*
  • Please select any that apply - Diabetes*
  • Please select any that apply - High blood pressure*
  • Please select any that apply - High cholesterol*
  • Please select any that apply - DVT*
  • Please select any that apply - Smoking*
  • Have you had any difficulty fully emptying your bowels during bowel preparation for a previous colonoscopy or endoscopy?

  • If you have previously had difficulty with bowel preparation, Dr Pratap may recommend an extended bowel preparation regimen if a colonoscopy is scheduled.

  • Do you take any blood thinners - anticoagulants or antiplatelets?*
  • What blood thinners do you take?*
  • Do you take any Diabetes, SGLT2 Inhibitor, or GLP-1 medications?*
  • What Diabetes, SGLT2 Inhibitor, or GLP-1 inhibitor medications do you take?*
  • Do you take any anti-hypertension medications?*
  • What anti-hypertension medications do you take?*
  • What other medications do you take (including vitamins and over the counter medicine?*

  • Patient Privacy Consent

  • Dr Krishan Pratap and their staff are committed to ensuring the privacy and confidentiality of your personal information.

    You have been referred to this practice for a medical consultation or examination and we collect information that is necessary to provide you with these health care services.

    We do require your consent to the collection, use and disclosure of your personal information.

    We may use your information among other health practitioners to provide your treatment, including but not limited to your referring doctor, your general practitioner and any other health service provider involved in your treatment and for providing you with health care services.

    We may work with contractors such as medical typists, data entry clerks and software developers who are located overseas. We may share access to your information with these contractors.

    You have the right to have access to the health information that we hold in your health record.

    The full Privacy Policy for Dr Krishan Pratap is available here.

     
  • Consent for Privacy Policy*

  • Payment Policy & Financial Consent

    • Payment: All appointment fees (for both in-person and telehealth) are due in full on the day of service.
    • Referrals: I am responsible for ensuring the practice has my valid, up-to-date referral before my appointment.
    • Cancellation: I must provide at least 24 hours (1 business day) notice to cancel or reschedule. I understand a cancellation fee will be charged for late cancellations or failure to attend.
    • Non-Payment: I understand that overdue accounts will be referred to a debt collection agency, and no further appointments will be offered until the balance is settled.

  • Patient Consent for Use of AI Dictation Software

  • I understand that Dr Krishan Pratap utilises artificial intelligence (AI) dictation software to transcribe patient notes and medical records. This software uses machine learning algorithms to convert speech to text in order to efficiently and accurately document patient encounters and medical information.

    I acknowledge and agree to the following:

    1. The AI dictation software will be used to transcribe information from my conversations with healthcare providers during office visits, procedures, or telehealth appointments. This may include details about my medical history, current health conditions, medications, treatment plans, and other relevant clinical information.
    2. The transcribed information will become part of my official medical record and may be used for various purposes, including but not limited to: documenting and communicating my care, supporting clinical decision-making, quality improvement initiatives, and billing and reimbursement.
    3. Appropriate technical, physical, and administrative safeguards are in place to protect the privacy and security of my information in accordance with the Australian Privacy Principles the privacy policies of Dr Krishan Pratap. Access to the AI-generated transcriptions will be limited to authorised staff involved in my care and others as permitted by law.
    4. While the AI dictation software strives for accuracy, occasional errors in transcription may occur. I have the right to review my medical records and request amendments as appropriate. Ultimate responsibility for the accuracy and completeness of the medical record rests with my treating providers.
    5. De-identified data from the AI-generated transcriptions may be used to help improve the performance of the dictation software. However, this data will not include my name or other directly identifying personal information.
  • Consent for AI Dictation*

  • Clinical Examinations

  • Dr Krishan Pratap may need to perform clinical examination and assessment as required during my appointment(s). 

    • I consent to my healthcare provider (and/or their qualified clinical team) performing the examinations and assessments they deem necessary. I understand this is to assess my health, make a diagnosis, develop a treatment plan, or monitor my progress.
    • I understand I have the right to ask questions about the purpose, nature, or any risks of an examination before it is performed. My provider will explain it to me in terms I can understand.
    • I understand that I can refuse a specific examination or withdraw my consent at any time (before or during the exam) without it affecting the quality of my future care.
  • Consent for Clinical Examinations*
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