Waitemata Endoscopy – Patient Pre-Assessment & Booking Form

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1 Page 6 2 Patient + Address 3 Procedure + Insurance 4 Medical History + Bowel Prep 5 Sedation + Pickup + Emergency 6 Information & Consent

Thank you for choosing Waitemata Endoscopy. 

Please complete this form as accurately as possible. The information you provide allows our clinical team to review your medical history, ensure your safety, and prepare appropriately for your procedure.

What happens next?

After you submit this form:

  • Our nursing team will review your information

  • A team member will contact you directly to arrange a convenient appointment date and time

  • We will discuss preparation instructions and answer any questions you may have

Most standard Gastroscopy and Colonoscopy procedures can be scheduled within 7 working days of referral when you allow us to match you with the earliest availability across our specialist team.* We accept GP, specialist, and self-referrals.

This form takes approximately 5 minutes to complete

Your information is confidential and reviewed only by our clinical and booking team.

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Part 1: Patient Details

Title *
First name(s) *
Surname *
Preferred name (if different)
NHI number
Date of birth *
Gender *
Ethnicity (optional)
Name of GP
GP Practice


Contact Information

Mobile phone *
Home phone (optional)
Email address *


Address

Residential address - Street *
Residential address - Suburb *
Residential address - City *
Residential address - Postcode *
Postal address *
Postal address - Street
Postal address - Suburb
Postal address - City
Postal address - Postcode


Residency & Interpreter

Are you a New Zealand resident? *
If no: Visa type and duration
Do you require an interpreter? (We do not arrange interpreter services.) *
Language required


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Part 2: Procedure and referral

Referral type *
Procedure type *
Reason for gastroscopy *
Reason for colonoscopy *
Other comments or reason for procedure *
Preferred doctor
Have you had this procedure before? (if yes, when, where and what was found)

Insurance details

Insurance name
Policy number
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Part 3: Medical History


Please indicate if you have any of these conditions

 

Add details if you have condition

 

Allergies (food, medications, latex)
Yes
No

 

Asthma, or breathing problems

Yes
No

 

Sleep apnoea

Yes
No

 

Heart conditions (incl stents, pacemaker)

Yes
No

 

High or low blood pressure

Yes
No

 

Diabetes

Yes
No

 

Seizures / epilepsy

Yes
No

 

Blood clotting disorder

Yes
No

 

Previous GI surgery or conditions

Yes
No

 

Joint replacements / metal implants

Yes
No

 

Pregnant or breastfeeding

Yes
No

 

Prostate problems

Yes
No

 

Hospital admission in the last 6 months

 

Yes
No

Medications


Please list all current medications (include over-the-counter and supplements).

Do you take blood-thinning medications? (e.g. warfarin, clopidogrel, apixaban, rivaroxaban) *
If Yes: dosage and time taken
Current weight (kg)
What is your current bowel habit? (e.g., once daily / diarrhoea / constipation)
Have you had difficulty with bowel prep before?
If yes, please explain what was the difficulty:

Dietary & Other Needs

Dietary requirements
Other dietary requirements (if Other)
Anything else you want us to know?
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Part 4 - Sedation and pickup person

Emergency Contact Person

Emergency Contact Name *
Emergency Contact Relationship
Emergency Contact Phone *
Who is picking you up after the procedure?
Pickup person - Name
Pickup person - Relationship
Pickup person - Phone
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Part 5 - Consent and submission

 

Thank you for filling our our endoscopy booking form. Please tick the boxes below to indicate you understand our standard terms and conditions. If you do not agree your booking won't be accepted. Please call our booking team to discuss any concern instead.

Once you submit the form, our booking team will review the information and contact you to arrange your booking or clarify any details if required.

I agree that the information submitted is true and correct.

Yes
No

I understand my visit may take approximately 2–3 hours.

Yes
No

I understand there will be nil by mouth instructions

Yes
No

I understand sedation options and risks will be explained

https://waitemataendoscopy.co.nz/endoscopies/sedation-info

Yes
No

I understand I must not drive for 12 hours after sedation

Yes
No

I understand someone will need to collect me after the procedure if I have sedation

Yes
No

I understand there will be bowel preparation instructions sent to me

Yes
No

Any late or non-payment by my medical insurer for hospital costs is my full responsibility.

Yes
No

I understand Waitemata Endoscopy may notify a credit-reporting agency after 90 days should I default, and unpaid accounts may incur collection fees

Yes
No

I consent to Waitemata Endoscopy collecting/storing my personal information and sharing as required with third parties involved with my care, as per the Privacy Statement:  https://waitemataendoscopy.co.nz/privacy

Yes
No

I consent to the use of AI tools during my visit. (Heidi is used to dictate the endoscopy report without any identifying information)

Yes
No

I consent to receiving communications and reports/letters via email or at the address provided.

Yes
No

Digital signature

Full name (type your name) *
Signature *
Clear
Date *
Submit
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