Melbourne Premier Gastroenterology | Online booking form

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ONLINE BOOKING FORM

Making an appointment with Premier Gastroenterology couldn't be easier.
Simply complete the form below and we'll contact you to confirm your
appointment date and time.

Please note: Your booking cannot be confirmed until we
have received a referral from your GP.

* Indicates required field

Which service do you require? *

Direct access endoscopy Consultation

First Name *

Last Name *

Date of birth (dd/mm/yyyy) *

Daytime phone number *

Email *

Referring GP *

Private Health Insurer *

Aged pensioner *

Have you had a colonoscopy before? *

Yes No

If yes, when? *

Do you have any of the following? *

Have you had any major abdominal surgery? *

Yes No

If yes, please supply further details *

Do you take any of the following medications? *

Blood thinners - eg. Asprin Iscover Plavix Xaralto Pradaxa Eliquis Warfarin Diabetes medications - eg. Insulin Diabex Diamicron

Which doctor would you like to see? *

Dr John Halliday Dr James Haridy Dr Rose Vaughan First available

My referral is being sent *

Yes

* Required

Submit

Premier Gastroenterology is fully committed to compliance with Data Protection and Department of Health medical confidentiality guidelines. The personal information that you submit using this form will be held securely by us and your personal information will not be shared with anyone outside of Premier Gastroenterology or used for any other purpose than to respond to your enquiry and / or request.

Download a referral form