Easy Access New Patients

01 Contact Information

Do you have Private Hospital insurance?*

Yes

Have you been with the fund for 12 months?

Yes

02 Who is your referring Doctor

03 Who is your current GP?

04 Reason for referral (tick which apply)

Positive FOBT result

Family history

Single first degree relative diagnosed with colorectal cancer under age 50

More than one relative with colorectal cancer

National Bowel Cancer Screening Program

History of colorectal polyps

History of colorectal cancer over 5 years ago

None of the above

05 Have you had a previous colonoscopy

Have you had a previous colonoscopy?

Yes

If yes:

06 Patient Health Assessment

Are you pregnant?

Yes

07 Symptom Check (tick which apply)

PR bleeding

Unexplained change in bowel habit

Abdominal pain

Faecal incontinence

Unexplained weight loss

None of the above

08 Medical Condition Check (tick which apply)

Diabetes

Cardiac Stent

Severe Heart Disease

Mental Illness

Dementia

Allergies

None of the above

09 Medication

Do you take blood thinning medication? (e.g. Clopidogrel, Dabigatran, Rivaroxaban, Apixaban, Aspirin,
Warfarin, Fish Oil)

Yes

List the medication & State the reason for blood thinning medication:

Do you take any other prescription, non-prescription or alternative medication?

Yes

List the medication

Do you take diabetic medications?

Yes

List the medication

10 Upload an image of Referral

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Doctor

Referral

Easy Access Colonoscopy

Easy Access Colonoscopy Request Form