Help us prepare for your upcoming appointment

Welcome to Upper Edge Surgery
Registration Form

We're here to make your care smooth, safe and well-coordinated. Please complete the patient registration form below so our team has everything they need to look after you.

Specialist surgeon
Minimally invasive & endoscopic surgery
Australian-trained (FRACS)

Register onlineTakes about 5–10 minutes — no account needed.

We confirm your detailsOur team checks your referral and cover. Nothing to pay now.

We book you inOur team reaches out to arrange the appointment that's most convenient for you — usually the same day.

Your specialist

Dr Goutham Sivasuthan Australian-trained Specialist Minimally Invasive & Endoscopic Surgeon (FRACS) — the same experienced hands from first consultation through your surgical care.

15%

1 · You 2 · Contacts 3 · Medicare 4 · History 5 · Preferences 6 · Consent

Fields marked * are required.

1 · Your details

First name

Middle name (optional)

Last name

Preferred name (optional)

Pronouns

Please specify

Date of birth

Sex (as on Medicare)

Best contact number (mobile)

Street address Address line 2 (optional)

Suburb

State

Postcode

Do you need an interpreter?

Yes No

Which language?

Current / previous occupation (optional) Reason for your visit (tick all that apply)

Bowel cancer screening (no symptoms) Positive FOBT / bowel screen result Rectal bleeding Change in bowel habit Abdominal pain Iron deficiency / anaemia Family history of bowel cancer Surveillance after previous polyps Reflux / upper-gut symptoms (gastroscopy) Other

2 · Emergency contact & doctor

Emergency contact

Contact name

Contact number

Relation to you (e.g. spouse, parent, adult child)

Treating doctor

Referring doctor (the doctor who referred you, if any)

Usual GP name

GP practice

Do you have a GP referral?

Yes, I have one Not yet

You can email your referral to us, or your GP can send it directly — we'll prompt you after you register.

3 · Medicare & insurance

Do you hold a valid Australian Medicare card?

Yes No

Medicare card number

Copy from your current card — the last digit changes when a card is reissued.

IRN (beside your name) The single digit beside your name on the Medicare card.

Card expiry I have a DVA (Veterans' Affairs) card Department of Veterans' Affairs card.

DVA card colour

DVA file number

No problem — you can still register. Our team will contact you about self-funded or overseas-visitor options before booking.

Are you under 18?

Yes No

Please give the parent/guardian's Medicare and details so we can confirm eligibility.

Guardian Medicare number

Guardian IRN

Guardian full legal name

Guardian date of birth

Do you have private hospital health insurance?

Yes No

Health fund

Name of your health fund

Membership number

Ref (if shown) The number beside your name on the fund card — it tells the fund which person on the membership you are. Often 1 or 01. Leave blank if your card doesn't show one.

Hospital cover level

Have you had private health insurance for more than 12 months?

Yes No

Thank you — that's helpful to know. Most funds apply a waiting period in the first 12 months of a new policy or after an upgrade, so your cover for this procedure may not have started yet. Our team will check your cover with your fund and talk you through any costs before anything is booked.

We are a no-gap provider for insured patients with most major funds — we'll confirm your cover before anything is booked.

Is this a Workcover or third-party claim?

Yes No

Claim / case number

Case manager (name + phone)

4 · Medical history

This helps us plan your sedation and procedure safely. Everything is encrypted before storage.

Relevant conditions (tick all that apply)

Cardiac / heart condition Diabetes High blood pressure Lung / respiratory disease Kidney disease Liver disease Thyroid / endocrine condition Stroke Bleeding disorder Other

Condition details (optional)

Do you have diabetes?

Yes No

How is your diabetes managed? (e.g. diet, tablets, insulin)

I take a GLP-1 medication (e.g. Ozempic, Wegovy, Mounjaro, Saxenda) I take a blood thinner (e.g. warfarin, apixaban, clopidogrel)

Which blood thinner(s)? (optional)

Do you have any allergies or adverse reactions?

Yes No known allergies

Add each allergen and the reaction it caused. Add a row for each one.

Do you smoke tobacco or vape?

Yes No Ex-smoker

Smoking detail (e.g. 20/day, quit 5 years ago)

Do you drink alcohol?

Yes No Prefer not to say

Alcohol detail (e.g. 2–3 drinks/week)

Height (cm)

Weight (kg)

Medications & dosages (one per line, e.g. "Metformin — 500mg twice daily")

5 · Preferences

Preferred appointment dates (optional, free text — e.g. "next 2–3 weeks", "anytime in July") How did you hear about us? (optional)

6 · Consent

I have read and agree to the Cancellation Policy and Zero Tolerance Policy below and the privacy policy, I consent to Upper Edge Surgery collecting my health information to arrange my care, and I authorise the release of relevant health information as described below. My details are encrypted before storage. I consent to being contacted by SMS and email about my appointments.

Read the policies (cancellation · zero tolerance · health information)

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

Upper Edge Surgery has a zero-tolerance approach to any verbal, aggressive or violent abuse and behaviour towards our doctors, staff or other patients. Abusive behaviour — including offensive language, yelling, verbal insults, physical violence, racial abuse or sexual harassment — will result in the person being required to leave the practice, and may mean care is transferred elsewhere; in extreme cases the police will be called. We have the right to refuse treatment to anyone who threatens the safety of our staff or patients.

Health information release

I give my consent to Dr Goutham Sivasuthan of Upper Edge Surgery to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care, and I authorise those practitioners or bodies to release such information (which may include sensitive health information) to Dr Sivasuthan and the practice. I authorise Dr Sivasuthan to include the medical practitioners I have named in patient correspondence (reports, letters or other means) as applicable to my care.

After you submit, we verify your details and our team reaches out to book you into the appointment that suits you best — usually the same day.

Welcome to Upper Edge SurgeryRegistration Form

1 · Your details

2 · Emergency contact & doctor

Emergency contact

Treating doctor

3 · Medicare & insurance

4 · Medical history

5 · Preferences

6 · Consent

Appointment Cancellation Policy

Zero Tolerance Policy

Health information release

Welcome to Upper Edge Surgery
Registration Form