Dr George Balalis | Direct Access Endoscopy Referral Form

PATIENT DETAILS

For suitable patients (without prior specialist consultation)

Full name *

DOB *

Contact number *

Email *

Address *

Medicare Number *

Private Health Fund

Private Health Number

Department of Veterans Affairs (DVA) Number

Procedures *

Gastroscopy

Colonoscopy

Gastroscopy - If other please describe

Colonoscopy - If other please describe

History *

Medical History - If other please describe

Doctor’s Name *

Doctor’s Practice *

Provider Number *

Signature *

Clear Signature

Are under 80 years of age
Able and willing to consent in English
Are fit and healthy
Have a current referral
Are not taking anticoagulant or blood thinning medication, aside from aspirin
Have no history of heart disease, obesity, diabetes, stroke, epilepsy, kidney or liver disease, or serious lung disease
Have somebody to transport them to and from the hospital
Have private health insurance or wish to have their colonoscopy in a private hospital
Note – if patients do not fulfill these criteria, they will need a consultation with Dr Balalis prior to their procedure

Send Direct Access Procedure Formonline, or via email, fax or post
Each Referral will be reviewed by Dr Balalis to confirm suitability
Patients will then be contacted by the practice to arrange a convenient time for the procedure and answer any questions
Any patient considered unsuitable for Direct Access will be offered an appointment to see Dr Balalis
Bowel Preparation Instructions - will be organised on discussion with Dr Balalis.

Patients will arrive at the hospital day procedure area
Dr Balalis will meet with the patient to review their history, discuss the procedure and gain informed consent
The procedure will be performed, with an anaesthetist administering the sedation
The results of the procedure will be discussed with the patient on the day, and a report sent to the referring doctor