Your personal details are safe and will not be stored except in the usual case of consultation. If for any reason you do not end up seeing one of our specialists, none of this information will be kept on our computer system.

For Medicare reasons, to be seen by a Specialist it is necessary to have a referral from a doctor.

Please complete this form as fully as possible. The details will assist us to give you the most suitable time and save you time on the telephone. Our reception staff will phone to confirm an appointment time within two working days.

items marked * must be completed

    Previous contact with GastroHealthCare

    Have you previously seen Prof Martin Veysey?

    Appointment requested


    GastroscopyColonoscopyCapsule EndoscopyOther

    Referring Doctor

    Which doctor requested the referral?

    Is this your General Practitioner (GP)?

    If not, who is your GP?

    Preferred time of appointment

    Best after:
    Best before:


    Details About Yourself


    Sex*: MaleFemale

    Residential Address*:


    Postal Address (if different):


    Medical registration numbers

    Medicare Number*:

    Health fund membership number:

    Pension number:

    Veterans affairs number:

    Healthcare card number:

    Gold card: YesNo

    Please prove you are human by selecting the flag.