NEW PATIENT REGISTRATION FORM

PATIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

PATIENT CONTACT DETAILS

Mobile Phone *

Best contact number (if different to mobile)

Email *

Address *

Postcode *

City / Suburb *

State

EMERGENCY CONTACT/ NEXT OF KIN

Name *

Mobile Phone *

REFERRING DOCTOR

Referring Doctor’s Name *Correspondence will automatically be sent to your referring doctor and copied to your GP/ local doctor. Please inform us if you do not want correspondence sent.

Address *

Family Doctor/ General Practitioner Name (if different to referring doctor)

Address

Please upload the referral from your doctor

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MEDICARE

Full Name on Medicare Card (if different to above)

Medicare Card No. *

Expiry *

Number next to your name on Medicare Card *

PRIVATE HEALTH INSURANCE

Do you have private health insurance? *

YesNo

If yes, does it include private hospital cover?

Name of insurance company

Membership No.

Expiry

MEDICAL HISTORY

Please outline the reason for your visit. For example, heavy menstrual bleeding, pelvic pain, ovarian cyst etc *

Please list any known medical conditions *

Please list any previous surgery/ procedure you have had *

Do you have any allergies, in particular to medications? If yes, please give details. If no allergies, write 'nil known' *

Please list any medications you are currently on or have recently been prescribed

Please list any over the counter medications, vitamins or supplements you currently or have recently used

Have you had a pelvic ultrasound recently? *

If yes, please attach the report

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If there is any other tests or scans you had recently, please attach the results

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What is your height? (cm) *

What is your weight? (kg) *

Do you smoke/ vape? If yes, please give approx. number/ week *

Do you drink alcohol? If yes, please write approx. number of standard drinks/ week *

Have you had any pregnancies? *

Yes No

If yes, please outline outcome of each pregnancies, and mode of delivery. For example, 2 children delivered at full term via normal vaginal delivery.

When was your last Cervical Screening Test (Pap smear)? What was the result? *

Do you have any family history of women's health issues? *

Yes No

If yes, please outline the details of the family history

Cancellation and Missed Appointment Policy

We value your time and strive to provide the best care possible.
To ensure that appointments run efficiently and to accommodate all patients, we have the following policy:

SMS appointment reminders will be sent 7 days before your scheduled appointment. Any appointment not confirmed by return SMS, email or phone call by 2 working days prior to your appointment, it will automatically be cancelled and will be offered to another patient on our waiting list.
We kindly request a minimum of 2 working days' notice for any cancellations or changes to your confirmed appointment.
Late cancellations (less than 2 working days) or missed appointments (no-shows) for the confirmed appointment will incur the full fee of consultation which is not covered by Medicare or private health insurance.
Repeated missed appointments may affect your ability to book future appointments.

By ticking the box, you acknowledge that you have read, understood, and agree to this cancellation policy.

*

AI Scribe Consent

To support accurate clinical documentation, our practice uses a secure, Australian Privacy Act–compliant AI scribe tool during consultations. This tool may transcribe and summarise parts of your visit to assist your treating practitioner and enhance your care. All data is de-identified, encrypted and securely and confidentially stored in servers located within Austrlia. No recordings are ever stored.

Your personal and health information is handled in accordance with the Australian Privacy Principles and our practice privacy policy.

By ticking this box, you consent to the use of this tool as part of your consultation. *

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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