Welcome to Colonoscopy Brisbane

Registration Form

Register once, and we'll verify your Medicare and health-fund details with our practice system. You'll then receive a personal link by SMS and email to book your telehealth consultation and your procedure — usually the same day, and always within 1 business day.

1 · You 2 · Contacts 3 · Medicare 4 · History 5 · Scope 6 · Consent

1 · Your details

First name

Middle name (optional)

Last name

Preferred name (optional)

Pronouns

Please specify

Date of birth

Sex (as on Medicare)

Best contact number (mobile)

Street address Address line 2 (optional)

Suburb

State

Postcode

Do you need an interpreter?

Yes No

Which language?

Current / previous occupation (optional) Reason for your visit (tick all that apply)

Bowel cancer screening (no symptoms) Positive FOBT / bowel screen result Rectal bleeding Change in bowel habit Abdominal pain Iron deficiency / anaemia Family history of bowel cancer Surveillance after previous polyps Reflux / upper-gut symptoms (gastroscopy) Other

2 · Emergency contact & doctor

Emergency contact

Contact name

Contact number

Relation to you (e.g. spouse, parent, adult child)

Treating doctor

Referring doctor (the doctor who referred you, if any)

Usual GP name

GP practice

Do you have a GP referral?

Yes, I have one Not yet

You can email your referral to us, or your GP can send it directly — we'll prompt you after you register.

3 · Medicare & insurance

Do you hold a valid Australian Medicare card?

Yes No

Medicare card number

IRN (beside your name) The single digit beside your name on the Medicare card.

Card expiry I have a DVA (Veterans' Affairs) card Department of Veterans' Affairs card.

DVA card colour

DVA file number

No problem — you can still register. Our team will contact you about self-funded or overseas-visitor options before booking.

Are you under 18?

Yes No

Please give the parent/guardian's Medicare and details so we can confirm eligibility.

Guardian Medicare number

Guardian IRN

Guardian full legal name

Guardian date of birth

Do you have private hospital health insurance?

Yes No

Health fund

Membership number

Hospital cover level

We are a no-gap provider for insured patients with most major funds — we'll confirm your cover before anything is booked.

Is this a Workcover or third-party claim?

Yes No

Claim / case number

Case manager (name + phone)

4 · Medical history

This helps us plan your sedation and procedure safely. Everything is encrypted before storage.

Relevant conditions (tick all that apply)

Cardiac / heart condition Diabetes High blood pressure Lung / respiratory disease Kidney disease Liver disease Bleeding disorder Other

Condition details (optional)

Do you have diabetes?

Yes No Prefer not to say

How is it managed? (e.g. diet, Metformin, insulin)

I take a GLP-1 medication (e.g. Ozempic, Wegovy, Mounjaro, Saxenda) I take a blood thinner (e.g. warfarin, apixaban, clopidogrel)

Which blood thinner(s)? (optional)

Allergies / adverse reactions (e.g. "Penicillin — rash". Leave blank if none.)

Do you smoke?

Yes No Ex-smoker

Smoking detail (e.g. 20/day, quit 5 years ago)

Do you drink alcohol?

Yes No Prefer not to say

Alcohol detail (e.g. 2–3 drinks/week)

Height (cm)

Weight (kg)

Medications & dosages (one per line, e.g. "Metformin 500mg")

5 · Previous scopes & surgery

Have you had a colonoscopy before?

Yes No

How long ago? (years)

Were polyps removed?

Have you had an upper endoscopy (gastroscopy) before?

Yes No

Were you told you have Barrett's oesophagus?

Have you had any other surgeries?

Yes No

Which surgeries?

Preferred procedure dates (optional, free text — e.g. "next 2–3 weeks", "anytime in July")

Your booking pathway

This is based on your answers above. Pricing is indicative — our team confirms your cover before anything is booked, and there's no payment to make now.

Answer "Do you have private hospital health insurance?" in Step 3 above and your pathway will appear here.

No-gap pathway

$0 surgeon fee. As a no-gap provider we cover the surgeon's fee for insured patients with most major funds. A hospital excess (typically ~$250–750, depending on your policy) and a small separate anaesthetist fee may apply.

We'll confirm your cover with your fund before anything is locked in.

Self-funded package

Fixed, all-inclusive from $1,650 (hospital, surgeon and anaesthetist), up to $1,950 for a combined gastroscopy + colonoscopy. Available at our package day-surgery hospitals (currently Springwood Day Surgery and North Lakes Day Hospital).

No private hospital cover needed. We'll confirm everything with you before anything is locked in.

Can you walk up two flights of stairs without stopping to catch your breath?

Yes No

To help us choose the safest hospital, please add your height and weight in Step 4 (Medical history) above.

Great — based on your answers you'll be able to choose your hospital and session directly when you book.

Thanks — based on your answers, our team will help choose the safest hospital for your procedure and will be in touch. You'll still be able to book your telehealth consultation straight away.

Preferred area (optional — just a hint; you'll pick your exact location and time when you book) How did you hear about us? (optional)

6 · Consent

I have read the privacy policy and consent to Colonoscopy Brisbane collecting my health information to arrange my care. My details are encrypted before storage. I consent to being contacted by SMS and email about my appointments.

Post-procedure telehealth review (bulk-billed)

After your endoscopy/colonoscopy, Dr Goutham Sivasuthan will see you for a short post-procedure review consultation, usually by telehealth. We bulk-bill this consultation. By assigning your Medicare benefit you agree the Medicare benefit is accepted as full payment for that consultation — you will have no out-of-pocket cost for it, and the benefit is paid directly to the practitioner. Assigning your benefit is your choice; you do not have to.

If you assign your benefit, you agree:
I assign my right to the Medicare benefit for any bulk-billed post-procedure review consultation related to this procedure, whether conducted in person or via telehealth (MBS item 91833 or equivalent), to Dr Goutham Sivasuthan, and request that the Medicare benefit be paid directly to the practitioner. I accept the assigned benefit as full payment for that consultation.

Do you assign your Medicare benefit for the bulk-billed post-procedure review?

Yes — I assign my benefit No — I'll pay the fee myself

Assigning your benefit is your choice and does not affect your registration. We only claim it after your review consultation has taken place.

After you submit, we verify your details and send your personal booking link — usually the same day.