Patient Registration

Doctor to consult with(Required)

Title

Name(Required)

Gender

Preferred Pronouns

Address(Required)

Home phone

Work phone

Mobile phone(Required)

Consent to be contacted via SMS(Required)

Email(Required)

Consent to be contacted via email(Required)

Have you been fully vaccinated against COVID-19?(Required)

Yes

Do you agree to have a medical student sit in on your consultation?(Required)

Yes

Note: Please enter 'Nil' if question doesn't apply.

Past surgery(Required)

Medical problems(Required)

Mental health problems(Required)

Do you have any neurodevelopmental or neurodivergent conditions?(Required)

Yes

Periods(Required)

Bladder problems(Required)

Bowel problems(Required)

Pregnancies, Births(Required)

Last Cervical Screening test (PAP)(Required)

Family history(Required)

Medications and Supplements(Required)

Allergies(Required)

Smoke? Drink alcohol? Any others?(Required)

Contraception?(Required)

I give my permission for my medical records to be obtained from or sent to any specified doctor and or medical institute. I give consent for my doctor to submit their account for my surgical procedure to my health fund on my behalf. I hereby agree to pay all costs incurred for my care and treatment by my doctor.(Required)

I agree

Patient registration

We kindly require a referral from your GP, along with any relevant test results, before we can schedule your appointment.

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