ENDOSCOPY Auckland

Name

Date of Birth

Phone number

Procedure

Appointment timeframe

Day

Doctor

Are you diabetic?

Yes No

Are you on blood thinners?

Yes No

Do you have a pacemaker?

Yes No

(Name of clinic visited)

Have you completed an online admission form?

Yes No

Please attach your GP/Specialist referral

(Maximum file size = 5 MB)