Ready to complete your booking with us?

This online pre-admission system will take approximately 5 to 10 minutes to complete.  H ave ready:  

• Your contact information, including next of kin

• Medicare card, any insurance you may have, etc
  

• Any medications you might take

We require your consent to enable us to handle personal information about you. Please read the privacy policy carefully, and acknowledge where indicated below. If you have any concerns or queries feel free to ask us for a further explanation.

I have had the opportunity to read this centre’s privacy policy and understand the reasons why my information must be collected. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the healthcare and treatment given to me. I understand that my healthcare is a partnership between me and the health professionals at Keilor Private and will take reasonable steps to ensure that I provide up-to-date contact information both now and in the future to enable Keilor Private to contact me for follow-up purposes.

I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any purpose other than set out above, my further consent will be obtained. 

Do you have a Medical Power of Attorney / Advanced Care Directive / Treament Limiting Order?

CONSENT FOR GASTROSCOPY

Gastroscopy is an invasive test to examine the oesophagus, stomach and duodenum. A long, thin, flexible tube is passed through the mouth to inspect the upper gastrointestinal tract. An anaesthetic (sedative) is given to ensure that no pain is felt during the procedure. Biopsies (tissue samples) are often taken and sent to a pathologist. Other procedures that may be performed include: removal of polyps (small benign growths), stretching of a narrowed oesophagus or therapy to treat bleeding (by injection, heat or the application of small clips).

Prior to the test you must not eat or drink anything, for at least 6 hours. The only exception is plain water, which can be drunk in small quantities, up until 3 hours before the procedure. If you have any serious heart, chest, kidney or other medical problems, are diabetic or taking anticoagulants (warfarin), you should inform the specialist who will be performing the procedure, as special precautions will need to be taken.

No single medical test is 100% accurate, and very rarely, a small cancer or other lesion (abnormality) can be missed. Rarely, gastroscopy cannot be completed, because of disease or other problems.

There are alternative tests to gastroscopy. Each treatment option has its own benefits and risks. You should discuss these with your doctor.

Complications: Gastroscopy is extremely safe and serious complications are very rare. Complications are more common when a therapeutic procedure is performed (stretching of the oesophagus, polyp removal etc.). The risk of complications is also higher when patients are elderly or have other serious medical problems.

Minor complications include:

• Bloating, nausea, throat and abdominal discomfort that can occur after the procedure. These are minor problems and generally settle promptly. A hoarse voice can also occur rarely.

• Fasting prior to the procedure can cause headaches, weakness or faintness.

• Occasionally patients can have bruising or pain at the site where sedatives have been injected.

Serious complications include, but are not limited to:

• Reaction or allergy to the sedatives and other medications used during the procedure.

• Perforation (making a hole in the wall of the gastrointestinal tract) and major bleeding. These are rare, but if they occur, may require hospitalisation, emergency surgery, blood transfusion or other treatments.

• Aspiration (vomiting of the stomach contents into the lungs) is also a rare complication, which may require hospitalisation.

• Every attempt is made to protect the teeth (including use of a special mouth guard), but on rare occasions, damage to teeth, crowns, plates and other dental devices can occur. The doctors and the hospital cannot be held responsible for such damage.

• Death, although extremely rare, is a possible consequence of any medical procedure. If you want further details of every rare complication, then you should indicate this to your doctor, before undertaking the procedure.

IF YOU DO NOT UNDERSTAND ANY OF THE ABOVE INFORMATION, OR HAVE FURTHER QUESTIONS OR CONCERNS, PLEASE TELEPHONE TO ARRANGE AN APPOINTMENT WITH THE SPECIALIST WHO WILL BE PERFORMING THE TEST.

CONSENT FOR COLONOSCOPY

Colonoscopy is an invasive test to examine the large bowel or colon. A long, thin, flexible tube is inserted through the anus to inspect the large bowel. An anaesthetic (sedative) is given to ensure that no pain is felt during the procedure. Biopsies (tissue samples) are often taken and sent to a pathologist.

Prior to your appointment you will be given a bowel preparation kit which will thoroughly clean your bowel and allow it to be successfully examined. If you have any serious heart, chest, kidney or other medical problems, are diabetic or taking anticoagulants (blood-thinners), special precautions will need to be taken to reduce any possible risk. You should inform the specialist who will be performing the procedure, BEFORE beginning the bowel preparation.

Cancer of the large bowel can arise from pre-existing polyps (benign wart like growths). Therefore, if any polyps are found, they are usually removed at the time of the procedure, while you are still sedated.

No single medical test is 100% accurate, and rarely, because of the anatomy of the bowel, or issues related to preparation, a small cancer or other lesion (abnormality) can be missed. Rarely, colonoscopy cannot be completed, due to bowel disease or other problems.

There are alternative tests to colonoscopy. Each treatment option has its own benefits and risks. You should discuss these with your doctor.

Complications:  For inspection of the bowel alone, complications are uncommon. Results from surveys, and from experience at our facility, show the chance of serious complications to be 1 in 1000 procedures or less. The risk of complications is higher, when patients are elderly or have other serious medical problems, when polyps are removed or when other extra procedures need to be performed.

Minor complications include:

• Bloating, nausea, throat and abdominal discomfort that can occur after the procedure. These are minor problems and generally settle promptly. Rarely, pain will last for a longer period of time and will require more extensive investigation and treatment.

• Intolerance to the bowel preparation can cause headaches, weakness and fainting. This is also a common problem which usually settles after the procedure.

• Occasionally patients can have bruising or pain at the site where sedatives have been injected.

Serious complications include, but are not limited to:

• Reaction or allergy to the sedatives and other medications used during the procedure.

• Perforation (making a hole in the wall of the bowel) and major bleeding. These are rare, but if they occur, may require hospitalisation, emergency surgery, blood transfusion or other treatments. Bleeding can occur up to 14 days after the procedure.

• Aspiration (vomiting of the stomach contents into the lungs) is also a rare complication, which may require hospitalisation.

• Every attempt is made to protect the teeth, but on rare occasions, damage to teeth, crowns, plates and other dental devices can occur. A hoarse voice can also occur rarely. The doctors and the hospital cannot be held responsible for such damage.

• Death, although extremely rare, is a possible consequence of any medical procedure. If you want further details of every rare complication, then you should indicate this to your doctor, before undertaking the procedure.

IF YOU DO NOT UNDERSTAND ANY OF THE ABOVE INFORMATION, OR HAVE FURTHER QUESTIONS OR CONCERNS, PLEASE TELEPHONE TO ARRANGE AN APPOINTMENT WITH THE SPECIALIST WHO WILL BE PERFORMING THE TEST.

The following information can be viewed and downloaded from:  https://www.keilorprivate.com.au/patient-information/

IMPORTANT

Five days before your procedure, stop taking iron tablets and avoid pips, seeds and grains.

Unless instructed otherwise, continue with all your medications up to and including the day of your procedure.

Bowel prep kits are available from Keilor Private. Please visit us to pick up a prep kit before your procedure. 

ONE DAY BEFORE YOUR PROCEDURE

• Follow the WHITE DIET instructions 

• Dinner must be completed by 6pm.

• After this time, no solid food or milk.

• Continue with clear liquids only.  

From7:00 pm to 8:00 pm

• Drink  PLENVU DOSE 1 mixture in one hour.

• Follow with 500 ml of clear fluids.

• Continue to drink clear fluids during the evening to remain hydrated but no solid food, or milk. 

Before bedtime, prepare DOSE 2 (using both sachets), and refrigerate.

ON THE DAY OF YOUR PROCEDURE

4 hours prior to arrival

Drink PLENVU DOSE 2 over 30 - 60 minutes - it can be diluted if too sweet. 

Follow with 500ml of clear fluids.

Continue to drink water to remain hydrated up to 2 hours prior to arrival. After this time, no more fluids.

If you take morning medications, take them now (unless instructed otherwise)

2 hours prior to arrival time

No fluids, no water, no liquids, nothing to eat, no chewing gum - nothing! 

Do you open your bowels daily?

IMPORTANT! 

For a successful colonoscopy, you need to do an extended bowel prep.  To achieve this, your diet must change in the lead up to your exam. This includes taking a laxative to soften stools and help with bowel preparation before your procedure. 

PREPARE FIVE DAYS BEFORE YOUR PROCEDURE

• Take 2x Movicol Sachets every night, for 5 days before your procedure. These are available at your local pharmacy.

• If you suffer from extreme constipation, extend your white diet to 3 days before your procedure.

• Drink plenty of fluids and be active.

More information:  https://www.keilorprivate.com.au/patient-information/

The following information can be viewed and downloaded from: https://www.keilorprivate.com.au/patient-information/

GASTROSCOPY FASTING INSTRUCTIONS

You must fast for 6 hours before your admission time. That means:

• No solid food including milk and chewing gum, 6 hours prior to admission. 

• No liquids, 2 hours before your admission time. 

Failure to fast will result in your procedure being cancelled. If unsure, please call Keilor Private for more advice 8340 6400

I have read and understood fasting instructions.

For patients having Colonoscopy, you understand white diet and bowel prep requirements

After your anaesthetic you will be unable to drive a car for the rest of the day, and  you must have a responsible adult pick you up and stay with you for the rest of the day, and overnight. You may NOT go home alone on public transport or walk home. A  responsible adult must be arranged BEFORE you arrive for your procedure.

Have you had a previous endoscopy procedure?

Family history of colon cancer?

Did you have polyps removed previously?

Do you wear glasses?

Do you wear hearing aids?

Are you currently pregnant and/or breast feeding?

Do you smoke or vape?

Do you consume alcohol?

Any loose teeth, caps, crowns or dental concerns?

Do you have any lung problems?

Do you have asthma?

Do you have sleep apnoea? 

Do you have any heart problems?

Have you had heart by-pass graft surgery? 

Do you have heart stents? Cardiac stents? 

Have you had a heart attack? Acute Myocardial infarction? 

Do you have heart failure? Congested Cardiac Failure? 

Have you had a heart valve replaced? 

Do you have an irregular heart (cardiac arrhythmia)?

Have you ever had a stroke?

Do you take aspirin?

Do you take an anticoagulant / blood thinner? EG, Apixaban, Clexane, Clopidogrel, Eliquis, Plavix, Warfarin, Xarelto, etc

Do you have high blood pressure? 

Do you have diabetes? 

Type 1 diabetes (e.g. insulin)?

Type 2 diabetes? (e.g. oral medications like Metformin,  Jardiance, etc).

Diet controlled diabetes?

Injections for diabetes or weight loss? EG, Ozempic

Do you have any liver problems?

Do you have hepatitis? 

Do you have jaundice?

Do you have pre-existing pain?

Do you have kidney problems?

Do you have high cholesterol? 

Do you have any skin issues?

Do you have any skin pressure injuries (EG, bruising, welts, sores)?

Do you have Epilespy?

Have you had a fit or seizure?

Have you ever had a fall? Or suffer from dizziness?

Do you have a mental illness?

Do you have Alzheimer's? 

Do you have Dementia?

Do you experience Delirium? 

Do you require assistance from a carer?

Any history of anxiety?

Have you ever had a panic attack? 

Other mental health concern not listed?

Please detail in the next section "...other medical condtion not listed" 

Please list any allergies to foods, tapes, and/or medicines

Have you ever had a significant anaesthetic problem?

Have you ever had a significant infection? For example, Carbapenem-resistant Enterobacteriaceae (CRE/CPE); and/or Methicillin-resistant Staphylococcus aureus (MRSA); and/or Vancomycin resistant enterococcus (VRE)

Are you, or someone you know, have an infectious disease in the past 2 weeks, i.e. chickenpox, measles, flu, COVID?

Have you returned from overseas travel in the past 4 to 6 weeks?

Have you stayed in an overseas hospital or care facility in the past 12 months?

Have you ever had Hepatitis B, C, or HIV?

Any other recent infection not listed above?

Costs associated with your procedure are available from one of our friendly staff at Keilor Private. 

For more information, please call (03) 8340 6400.

If you need to reschedule, please inform us at least 1 week prior to your procedure day. This allows us to offer this appointment slot to other patients who have an immediate need for our care. If you cancel your procedure with less than a week’s notice, you could be issued with a cancelation fee of $80.

You have an opportunity to discuss the reason for your procedure, its benefits, risks, financial costs and alternative options before deciding to proceed.  

If you have any health or medication concerns, please tick yes and a nurse will call you before your procedure.