Waitemata Endoscopy – Patient Pre-Assessment & Booking Form

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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 booking team will review your information

  • A staff 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 procedure *
Preferred doctor
Do you have a referred location, date or time?
Have you had this procedure before? *
When and where? (if Yes)

Insurance details

Insurance name
Policy number
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Part 3: Medical History

 

Add details if you have condition

 

Allergies (food, medications, latex)
Yes

 

Asthma, or breathing problems

Yes

 

Sleep apnoea

Yes

 

Heart conditions (incl stents, pacemaker)

Yes

 

High or low blood pressure

Yes

 

Diabetes

Yes

 

Seizures / epilepsy

Yes

 

Blood clotting disorder

Yes

 

Previous GI surgery or conditions

Yes

 

Joint replacements / metal implants

Yes

 

Pregnant or breastfeeding

Yes

 

Prostate problems 

Yes

 

Hospital admission in last 6 months?

Yes

Medications

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

Medications
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?
Please explain including which prep was taken (if Yes)

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

For detailed explanation on sedation options please read:

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

Person collecting you after the procedure

Would you like sedation for your procedure?
What is your sedation preference?
Important sedation information*
I understand I must not drive for 12 hours after sedation
I understand someone will need to collect me after the procedure
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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 terms and conditions. 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
 
I understand my visit may take approximately 2–3 hours


Yes
 
I understand there will be nil by mouth instructions


Yes
 
I understand sedation options and risks will be explained


Yes
 
I understand there will be bowel preparation instructions sent to me


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


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


Yes
 
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
 
I consent to the use of AI tools during my visit.


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


Yes

Digital signature

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