Patient's Details
*Surnames
*DOB
01
02
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04
05
06
07
08
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10
11
12
13
14
15
16
17
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25
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31
01
02
03
04
05
06
07
08
09
10
11
12
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
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1983
1982
1981
1980
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1977
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1975
1974
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1971
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1967
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1965
1964
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1962
1961
1960
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1956
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1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
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1941
1940
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1938
1937
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
*First Names
NHI
*Address
Tel (home)
Tel (work)
Insurer
Tel (mobile)
*Request
Colonoscopy
Consultation
Gastroscopy
Bowel cancer screening
*Clinical Details
Comorbid conditions
Drugs
Cardiac
Warfarin/Clopidogrel
Respiratory
Aspirin/NSAIDS
Diabetes mellitus
Allergies or anaesthetic problems
Other
Other
Referring Doctor
Preferred report type
*Name
Telephone
Medical Centre
Fax
*Postal Address
Email
EDI Report to:
*NZMC#
*Validation Code
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