Dr. Bernard Beldholm M.B.B.S B.Sc (Med), FRACS (Specialist Surgeon by jxr17653


									           Dr. Bernard Beldholm M.B.B.S B.Sc (Med), FRACS (Specialist Surgeon)
           117 Mt Pleasant St                                                                  Ph:(02) 49319299
           Maitland, NSW 2320                                                                   Fax:(02) 49329132
           www.beldholm.com                                                                    info@beldholm.com
                                           Open access endoscopy service
                                       GP referral form (http://www.beldholm.com/fast.pdf)
                  Procedure requested (please tick)                         Procedure for booking
Colonoscopy O give info http://www.beldholm.com/colonoscopy.pdf             1. Fill in form and fax to rooms
Gastroscopy O give info http://www.beldholm.com/gastroscopy.pdf             2. Provide patient with info on procedure or
Haemorrhoid banding O info http://www.beldholm.com/haemorrhoid.pdf             direct to web site or rooms
Post procedure consultation required ? Y / N                                3. Patient calls rooms and gets procedure date
Patient has private health insurance(12months+)/DVA O (Required)            4. Dr. Beldholm will see patient on day of
                                                                               procedure in rooms and completes consent
                      Indications (please tick)                                form prior to patient going to Private
 Gastroscopy                       Colonoscopy                                 Hospital
 GORD                         O FOBT positive               O               5. Patient is followed up in rooms as required.
 Epigastric pain              O Bright red PR bleeding      O                  All patients with abnormal results will be
                                                                               requested to come for consultation.
 Follow up peptic ulcer       O Screening post bowel cancer O
                                                                            6. All patients are told results of procedure prior
 Screening Barrett’s          O Follow up screening         O                  to discharge from Private Hospital
 Anaemia unknown origin        O Ulcerative colitis         O
                                                                            Procedure information
 Malaena                       O Crohn's disease            O               Procedure date usually available within 2 weeks
                                   Anaemia unknown origin   O               Endoscopy done at Maitland Private Hospital
Other indication (please D/W Dr. Beldholm prior to booking open access)
                                                                            Patient needs to have Private Health Insurance,
                                                                            DVA, workers comp or pay for the procedure.
                                                                            Procedure charged No-Gap (at no cost to patient)
                                                                            Patients need to have minimal co-morbidities. If
Clinical details (if significant co-morbidity not for open access)          patient has major co-morbidities or other
                                                                            complicating matters then refer patient for a full
                                                                                 Patient Instructions (Summary)
                                                               Gastroscopy: Nothing to eat or drink six hours
Anticoagulants ( need to be ceased prior to procedure)         prior to the procedure
                                                               1 week before colonscopy: Stop these
                                                               medications - aspirin, clopidrogel(eg. Plavix,
                           Patient Details                     Iscover), dipyridamole (eg Asasantin, Persantin).
Patient Name:_____________________________ Sex (circle): M / F 5 days before colonoscopy: If you are taking
Address:_________________________________________________ warfarin (Coumadin, Marevan), stop taking
DOB: ___________Phone:____________ Mobile:_______________ however always check with GP first
Private Health Insurance Fund:_______________________________ 2 days before colonoscopy: Take only low-
Membership number:______________________________________       residue foods eg white bread, white rice, eggs,
DVA Gold Card                                                  potato without the skin. Do NOT eat vegetables,
Number:____________________________________                    fruits or anything high in fibre
                          Referring Doctor                     1 day before colonoscopy:
Referring Doctor’s Name:___________________________________  DRINK CLEAR FLUIDS ONLY and take no
Provider No:_____________________________________________           food at all. Clear fluids include - water, black
Address:_________________________________________________           tea WITHOUT milk, clear fruit juices
Phone:__________________________________________________            without pulps, clear soup, soft drinks, mineral
Fax:_____________________________________________________           water and cordial
                                                                Take 2 sachets of PICOPREP
Signature:___________________________                           Nothing to eat or drink six hours prior to the
Date:____________________                                           procedure

                                         Dr. Bernard Beldholm, Ph: (02) 49319299, Fax: (02) 49329132

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