Help us prepare for your upcoming procedure

Welcome to Colonoscopy Brisbane

Registration Form

We’re here to make your experience smooth, safe and stress-free. Please complete the patient registration form below so our team has all the information needed to support you throughout your care.

Before you register

Tell us which procedure dates suit you best

Use the rotating calendar below to select up to three preferred procedure dates, ranked in order of preference. Simply tap a session to add that date to your selection, and tap it again to remove it.

Each date is treated as a separate preference, even if it is at the same hospital, so you can choose and rank multiple dates at the same location (for example, two different Mater Redland sessions).

A brief hospital summary and location map will be displayed alongside the calendar to help you choose the most convenient site.

Your selections will be automatically added to your registration form. Please note that these are preferred dates only. Our team will contact you to confirm the final procedure date and hospital, taking into account clinical suitability, procedure requirements, theatre availability, and health fund eligibility.

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Uninsured or self-funded? Fixed-price package available

If you do not have private health insurance and would like our fixed-price colonoscopy package, your procedure must be booked at one of our two day-hospital sites:

North Lakes Day Hospital Springwood Day Surgery

Choose a date at one of these gold-tagged sites in the calendar below to access package pricing. Our team confirms all inclusions and the total cost before any procedure is booked.

Your preferred dates

This list fills in as you choose. Your first pick becomes preference 1, your second pick preference 2, and so on (up to 3 dates).

  • No dates chosen yet. Tap a session in the calendar to add your first preferred date.

You can choose up to 3 dates. Remove one to add another.

Upcoming procedure locations

Indicative 4-week rotating schedule. Tap a session to choose that specific date.

Fixed price = site where the fixed-price package is available for uninsured patients (North Lakes and Springwood).
Continue to registration form Your date preferences are saved with your registration automatically.

PERSONAL DETAILS

Patient Name
Home Address (per Medicare/Insurance registration)
Drag & Drop Files, Choose Files to Upload
If you already have a referral from your GP, attach it here. PDF, image or document, up to 10 MB. This is optional and helps us process your booking faster.
Do you require an interpreter for your consultations?

EMERGENCY CONTACT INFORMATION

TREATING DOCTOR

MEDICARE / INSURANCE DETAILS

Do you currently hold a valid Australian Medicare card?
Are you (the patient) under the age of 18?
If under the age of 18, further questions will appear for the parent/guardian to complete for Medicare
Do you have Private Health Hospital cover?
Are you a DVA member?
Are you a Workcover or Third Party Claim patient?

MEDICAL HISTORY

Do you have any of the following medical conditions?
Please tick all the relevant sections
Do you have diabetes?
Are you taking any weightloss medications (Ozempic/Wegovy/Saxanda)?
If Yes, you will be required to have a special fasting diet of clear fluids for 24 hours prior to your procedure
Are you on any blood thinning medication (Aspirin/Eliquis/Pradaxa/Plavix/Xarelto)?
Have you had any previous surgeries?
Do you have any allergies or adverse drug reactions?
Do you smoke tobacco or vape?
Do you drink alcohol?

Please list all your medication and dosages (where possible)

SURVEILLANCE SCOPE

Have you previously had a Colonoscopy?
Have you previously had an Endoscopy/Gastroscopy?

TERMS OF SERVICE

Cancellation Policy
Colonoscopy Brisbane – Appointment Cancellation Policy

If appointments are cancelled within 48 hours of the scheduled appointment, a $100 cancellation fee will be charged.

If an appointment is cancelled within 24 hours, or if a patient does not attend, a $100 cancellation fee will be charged.

No further appointments will be made until the cancellation fee has been paid.

If the patient is a WorkCover, DVA, or ADF patient, this cancellation fee must be paid by the patient personally and will not be covered by the third party.
Zero Tolerance Policy
Colonoscopy Brisbane – Zero Tolerance Policy

The practice of Colonoscopy Brisbane (“this Practice”) has a ZERO TOLERANCE approach to any verbal, aggressive or violent abuse and behaviour towards our doctors, staff, or other patients. Our doctors and practice staff have a right to care for others without fear of being attacked or abused.

To successfully provide these services, mutual respect between all staff and patients must be maintained.

Dealing with people who are abusive or aggressive towards our staff and patients takes us away from caring for you. All our staff aim to be polite, helpful, and sensitive to all patients’ individual needs and circumstances.

Our staff understand that patients who are in significant pain do not always act in a reasonable manner and will take this into consideration when trying to deal with a misunderstanding or complaint.

However, aggressive behaviour — whether violent or abusive — will not be tolerated. Abusers will be required to leave the Practice and may be asked to transfer their care elsewhere. In extreme cases, including refusal to leave the Practice, the police will be called.

We have the right to refuse treatment and take further action against anyone who threatens the safety of our staff or our patients.

In order for the practice to maintain good relationships with patients, we ask all patients to read and take note of the types of behaviour that are considered unacceptable:
• Using offensive language or swearing at practice staff
• Using a raised voice or yelling in an angry manner at practice staff
• Any physical violence towards any member of the Practice team or other patients, including pushing or shoving
• Verbal abuse towards staff in any form, including verbal insults
• Racial abuse and sexual harassment (will not be tolerated under any circumstances)
• Persistent or unrealistic demands that cause stress to staff (requests will be met wherever possible and explanations provided when they cannot)
• Causing damage to or stealing from the Practice’s premises, staff, or patients
• Obtaining drugs and/or medical services fraudulently
Privacy Policy
I give my consent to Dr Goutham Sivasuthan of Colonoscopy Brisbane to contact medical practitioners or other bodies I have consulted to obtain health and other
information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health
information to Dr Sivasuthan and their practice as may be requested. This is in line with the National Privacy Act, updated 1st November 2010. I authorise Dr
Sivasuthan to include the medical practitioners or other specialists I have named in patient correspondence, in the form of reports, letters or any other means as
deemed applicable by Dr Sivasuthan.

Introduction
Our practice is committed to best practice in relation to the management of the information we collect. This practice has developed a policy to protect patient privacy in compliance with the Privacy Act 1988 (Cth) (‘the Privacy Act’). Our policy is to inform you of:
the kinds of information that we collect and hold, which, as a medical practice, is likely to be ‘health information’ for the purposes of the Privacy Act;
how we collect and hold personal information;
the purposes for which we collect, hold, use and disclose personal information;
how you may access your personal information and seek the correction of that information;
how you may complain about a breach of the Australian Privacy Principles and how we will deal with such a complaint;
whether we are likely to disclose personal information to overseas recipients;
we will obtain your written permission prior to disclosure of your personal information to any overseas entity or recipient.

What kinds of personal information do we collect?
The type of information we may collect and hold includes:
Your name, address, date of birth, email and contact details
Medicare number, DVA number and other government identifiers, although we will not use these for the purposes of identifying you in our practice
Other health information about you, including: notes of your symptoms or diagnosis and the treatment given to you; your specialist reports and test results; your appointment and billing details; your prescriptions and other pharmaceutical purchases; your genetic information; your healthcare identifier; any other information about your race, sexuality or religion, when collected by a health service provider

How do we collect and hold personal information?
We will generally collect personal information:
From you directly when you provide your details to us. This might be via a face to face discussion, telephone conversation, registration form or online form.
From a person responsible for you.
From third parties where the Privacy Act or other law allows it – this may include, but is not limited to: other members of your treating team, diagnostic centres, specialists, hospitals, the My Health Record system, electronic prescription services, Medicare, your health insurer, the Pharmaceutical Benefits Scheme.

Why do we collect, hold, use and disclose personal information?
In general, we collect, hold, use and disclose your personal information for the following purposes:
How do we collect and hold personal information?
We will generally collect personal information:
From you directly when you provide your details to us. This might be via a face to face discussion, telephone conversation, registration form or online form.
From a person responsible for you.
From third parties where the Privacy Act or other law allows it – this may include, but is not limited to: other members of your treating team, diagnostic centres, specialists, hospitals, the My Health Record system, electronic prescription services, Medicare, your health insurer, the Pharmaceutical Benefits Scheme.

Why do we collect, hold, use and disclose personal information?
In general, we collect, hold, use and disclose your personal information for the following purposes:
To provide health services to you.
To communicate with you in relation to the health service being provided to you.
To comply with our legal obligations, including, but not limited to, mandatory notification of communicable diseases or mandatory reporting under applicable child protection legislation.
To help us manage our accounts and administrative services, including billing, arrangements with health funds, pursuing unpaid accounts, management of our ITC systems.
For consultations with other doctors and allied health professional involved in your healthcare.
To obtain, analyse and discuss test results from diagnostic and pathology laboratories.
For identification and insurance claiming.
If you have a My Health Record, to upload your personal information to, and download your personal information from, the My Health Record system.
Information can also be disclosed through an electronic transfer of prescriptions service.
To liaise with your health fund, government and regulatory bodies such as Medicare, the Department of Veteran’s Affairs and the Office of the Australian Information Commissioner (OAIC) (if you make a privacy complaint to the OAIC), as necessary.

How can you access and correct your personal information?
You have a right to seek access to, and correction of the personal information which we hold about you. For details on how to access and correct your health record, please contact our practice as noted below under ‘Contact Details’: We will normally respond to your request within 30 days.

How do we hold your personal information?
Our staff are trained and required to respect and protect your privacy. We take reasonable steps to protect information held from misuse and loss and from unauthorised access, modification or disclosure. This includes:
Holding your information on an encrypted database.
Holding your information in secure cloud storage (you can explain whether this information is encrypted or what other security measures are taken with third party storage).
Our staff sign confidentiality agreements.

Privacy-related questions and complaints
If you have any questions about privacy-related issues or wish to complain about a breach of the Australian Privacy Principles or the handling of your personal information by us, you may lodge your complaint in writing to (see below for details). We will normally respond to your request within 30 days.
If you are dissatisfied with our response, you may refer the matter to the OAIC:
Phone: 1300 363 992
Email: [email protected]
Fax: (02) 9284 9666
Post: GPO Box 5218, Sydney NSW 2001
Website: https://www.oaic.gov.au/privacy/privacy-complaints

Anonymity and pseudonyms
The Privacy Act provides that individuals must have the option of not identifying themselves, or of using a pseudonym, when dealing with our practice, except in certain circumstances, such as where it is impracticable for us to deal with you if you have not identified yourself. We have determined that it is largely impracticable for our practice to deal with patients anonymously or via a pseudonym. The provision of medical services is likely to be impacted, and billing via Medicare or a health insurer where applicable is likely to be impracticable. Therefore, we require that you use your name and not a pseudonym.

Overseas disclosure
We may disclose your personal information to the following overseas recipients:
Any practice or individual who assists us in providing services (such as where you have come from overseas and had your health record transferred from overseas or have treatment continuing from an overseas provider).
Anyone else to whom you authorise us to disclose it.

Updates to this Policy
This Policy will be reviewed from time to time to take account of new laws and technology, changes to our operations and other necessary developments.
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