Book an Endoscopy

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

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

If the submit button does not work, this could be due to a privacy/ad blocker. Our apologies, please call us on 09 925 4449

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© 2026 Waitemata Endoscopy
Phone: (09) 925 4449 Email: admin@waitemataendoscopy.co.nz
WE // North Shore // 212 Wairau Road, Entrance A, Wairau Valley, Auckland 0627
WE // West // 53 Lincoln Road, Henderson, Auckland 0610