Booking Form

Medical Assessment - Ivanhoe Endoscopy Centre

IVANHOE ENDOSCOPY CENTRE

Medical Assessment

Form: QF-11-01

Fields marked with * and shown with a highlighted background are required. Please make sure these are completed before submitting.

1 Booking Details

2 Patient Details

New Patient?

Billing & Insurance

Concession Cards
PHI (Private Health Insurance)?

Attach your referral letter securely directly to our system.

Staff available to assist on the day?

3 Suitability for Procedure

Medical History Questionnaire * Yes No
Diabetes — if you are diabetic, please select your treatment type: *
Do you weigh over 120kg or BMI over 35? *

4 Medications

Any anti-coagulant and or blood thinners? (e.g. Plavix, Iscover, Clopidogrel, Coplavix, Prasugrel, Pradaxa, Warfarin) *
Taking more than 4 medications? *
Are you taking any medication or injection for weight loss management? *

Your data is transmitted securely.

The Ivanhoe Endoscopy Centre is a specialist day surgery for the investigation and treatment of digestive disorders.

Opening Hours

  • Monday 9:00 AM - 5:00 PM
  • Tuesday 7:30 AM - 5:00 PM
  • Wednesday 7:30 AM - 5:00 PM
  • Thursday 9:00 AM - 5:00 PM
  • Friday 7:30 AM - 5:00 PM
  • Saturday Closed -
  • Sunday Closed -

Contact Info

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