Northside Endoscopy Service
Phone: 1300 733 801
Or phone: 5498 9077
Fax: 07 5432 4168
Dr Andrew Hallam | Dr Andrew Lee | Dr Marnie Wood | Dr Mahesh Jayanna |
Dr Rajeev Sinniah

	Consultations					Day Surgery
	NES Caboolture Day Endoscopy Unit, 17 Hasking Street			NES Caboolture
	Chermside Holy Spirit Northside, Level 1 Medical Suites, 627 Rode Rd		Caboolture Private	
	Kippa-Ring Peninsula Specialist Centre, Suite 23 George Street		Holy Spirit North
	Strathpine Specialist Centre, Suite 9 Dixon Street			Peninsula Private
	North Lakes QML Specialist Rooms, 10 Endeavour Blvd			North Lakes
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Date: <<Miscellaneous:Date (long)>>

Patient Details:
Re:   <<Patient Demographics:Full Name>>
Preferred name: <<Patient preferred name>>
DOB: <<Patient Demographics:DOB>>     Age: <<Patient Demographics:Age>>     Sex: <<Patient Demographics:Sex>>
Address:   
<<Patient Demographics:Full Address>>

Phone (Home): <<Patient Demographics:Phone (Home)>>
Phone (Work): <<Patient Demographics:Phone (Work)>>
Phone (Mobile): <<Patient Demographics:Phone (Mobile)>>

Aboriginal or Torres Strait Islander origin: <<Aboriginal or Torres Strait Islander origin>>
Interpreter Required: <<Interpreter required>>      Preferred Language: <<If yes, what is the preferred language>>
Medicare Number: <<Patient Demographics:Medicare Number>>
DVA Number: <<Patient Demographics:DVA Number>>      DVA Card Type: <<DVA Card Type>>
Occupation: <<Patient Demographics:Occupation>>
Health Insurance Provider: <<Patient Demographics:Health Insurance>>
Workers Compensation claim details: <<Workers compensation claim details:>>

Referring General Practitioner:
Doctor : <<Doctor:Name>>
Provider No.: <<Doctor:Provider Number>>
Doctor Address:
 <<Practice:Name>>
 <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>

Patient’s Usual G.P. (if different from referrer) <<Patient’s Usual G.P. (if different from referrer)>>
Is anyone else involved in the care of the patient?: <<Is anyone else involved in the care of the patient?>>

Request for Colonoscopy: <<Colonoscopy request>>
Reason for Colonoscopy: <<Colonoscopy reason>>
Other reason: <<Colonoscopy other reason>>

Requesy for Gastroscopy: <<Gastroscopy request>>
Reason for Gastroscopy: <<Gastroscopy reason>>
Other reason: <<Gastroscopy other reason>>

Past Medical History:
<<Clinical Details:History List>>

Signature: _________________________________________________________

COLONOSCOPY PATIENTS
Instruction/Prep kit needs to be collected
UPPER ENDOSCOPY PATIENTS
Endoscopy involves the use of a narrow, flexible tube (a gastroscope) to examine the upper intestinal tract.  You must have nothing to eat or drink for SIX HOURS before the procedure.  If your booking is in the afternoon you may have a light breakfast of toast and tea.
If you take any medication for your heart or blood pressure, it is important you take these as usual with a sip of water as early as possible before the procedure.  If you are a diabetic or on blood thinning medication please inform the receptionist when making your booking.
You will be given a light anaesthetic to make you relaxed and comfortable.  Once this has taken effect the doctor will pass the gastroscope via the mouth to examine, and if necessary take biopsies from the oesophagus, stomach and duodenum.
Endoscopy is not painful and you may have no memory of it afterwards.  The procedure takes 5 to 15 minutes to perform and you will be sleepy for about another half an hour.
REMEMBER   – FAST FOR SIX HOURS
– DO NOT RETURN TO WORK. ARRANGE A DRIVER
– HAVE SOMEONE WITH YOU FOR 12 HOURS AFTER PROCEDURE