Riverview Endoscopy
Riverview Endoscopy
at Hollywood Specialist Centre
13/95 Monash Ave, Nedlands, Western Australia
1800-174-837 (1800-1-RIVER)
Fax 08-9389-5322
Return to Capsule® Background or Capsule® Instructions.
I have received, read and understood the Information Sheet "Patient Instructions for Undergoing Given® Capsule Endoscopy".
I have had an opportunity to discuss this with Dr Mollison.
I understand that the Capsule is normally passed naturally with a bowel action but that in rare
cases obstruction may occur and it may then need to be removed surgically.
I understand that the Capsule System has been approved for medical use in Australia
To help ensure that the investigation is used appropriately on me and is also of value to me, I consent to the release of information detailing previous investigations related to the abdominal complaints for which I am now being evaluated, by any Medical Practitioner I have consulted in the past, and I consent to the release of results of investigations performed relevant to these abdominal complaints, by any Medical Practitioner I may consult within the next twelve months, to
Dr Mollison and/or his staff.
I agree to answer questions by telephone each three months for the next twelve months regarding my medical progress related to these complaints.
I agree to pay the costs of undergoing the Capsule Endoscopy test itself.
I understand that for rebates to be available from Medicare or any private health fund (health insurance company) for the costs of the Capsule Endoscopy Test itself, certain qualifying conditions must be met.
I agree to pay any relevant consultation fees to Dr Mollison. (If incurred, Medicare usually largely
refunds these).
I agree to pay fees for any other tests, consultations or procedures that may be necessary.
I hereby agree to undergo capsule endoscopy.
Name: Patient ................................. Witness ..................................
Signed: ................................. ..................................
Date: .................................. .................................
Presented by Dr Lindsay C MollisonRiverview Endoscopy Home Page
Disclaimer
Created 14 November 2001
Updated 14 May 2010
Comments Welcomed.