Recall Dr Engelman

Please fill in the information below and we will be in contact with an appointment or procedure date.

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Name:

DOB:

Email:*

Contact Number:

What was your recall for?*

Gastroscopy
Colonoscopy
Gastroscopy and Colonoscopy
Capsule Endoscopy

Have you had major chest pain or a heart attack within the past 3 months?*

Yes
No

Have you had a stroke within the past 3 months?*

Yes
No

Do you have problems performing your daily chores or shopping without getting short of breath?*

Yes
No

Do you take blood-thinning medication such as any Aspirin preparation, Astrix, Cartia, Cardiprim, Plavix, Iscover, Persantin, Asasantin or Warfarin because of heart valve replacement or a recent stroke or a heart attack?*

Yes
No

Are you older than 75?*

Yes
No

Are you diabetic requiring insulin or medications?*

Yes
No

Do you have any concerns about your fitness for a general anaesthetic?*

Yes
No

Do you have any concerns about the need for this procedure?*

Yes
No

Do you have a new referral from your GP? A valid referral must be sent to our rooms prior to arranging dates for this procedure*

Yes
No

Are you in a health fund with hospital cover or are you a public patient?*

Health Fund
Public

What day do you prefer to have your procedure? If you are a public patient please skip this question*

Monday (Prince of Wales Hospital)
Wednesday (Double Bay Day Hospital)
Thursday (Double Bay Hospital)
Next Available

Do you have any questions or preference?

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