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
Caboolture Private | St Vincents Northside | Peninsula Private | Moreton Day Hosp

Day Surgery
Caboolture Private Hospital, Suite 1, McKean St
Chermside St Vincents Northside, Level 1 Medical Suites, 627 Rode Rd
Kippa-Ring Peninsula Specialist Centre, Suite 23 George Street
North Lakes Specialist Center Suite 506 Level 5, 6 North Lakes Dr
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Date: Miscellaneous.Date

Patient Details:
RE: Patient Demographics.Full Name
DOB: Patient Demographics.DOB Age: Patient Demographics.Age Sex:Patient Demographics.Gender
Address: Patient Demographics.Address
Phone: Patient Demographics.Phone (Home), Patient Demographics.Phone (Mobile)

Referring General Practitioner:Treating Doctor:Name
Address: Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Email: Treating Doctor.E-mail
Provider Number: Treating Doctor.Provider Number

Request for Colonoscopy:
Other Reason: 

Request for Gastroscopy: 
Other Reason: 

Past Medical History:
Clinical Details.History List
Current Medications:
Clinical Details.Medication List
(Please include specifically if patient is on: Insulin, Warfarin, Clopidogrel, Iscover, Plavix, Pradaxa or Aspirin)

Signature: __________________________________________________
		Treating Doctor.Name	Miscellaneous.Date

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

DVA Number: Patient Demographics.DVA Number
Insurance: Patient Demographics.Health Insurance
Medicare Number: Patient Demographics.Medicare Number
Pension Number: Patient Demographics.Pension Number