Book an Appointment - Melbourne Fertility & Endosurgery Centre

Name*

First Last

Salutation*

Preferred Name*

Date of Birth*

Height*

Weight*

Do you smoke

Email*

Address*

Post Code*

Occupation*

Marital Status*

Mobile*

Phone (H)*

Phone (W)

Next of Kin/Partners Name*

Relationship*

Partner Date of Birth*

Next of Kin/Partner Mobile*

Next of Kin/Partner Email*

Health Insurance Fund*

(HIF) Number*

Medicare Number*

Ref. Number (before your name)*

Next of Kin Medicare Number*

Next of Kin Ref. Number (before your name)*

Select as Appropriate

Expiry Date

Number

Referring Doctor*

Usual GP*

Please indicate any major illnesses or operations in the past*

Do you take any "blood thinners" eg Warfarin, Clopidogrel, Aspirin, Iscover?*

Yes
No

Please list other medications (including "natural therapies")

Please list any allergies

How did you find out about us?*

Fertility patients please complete the following:

Have you ever had a pregnancy?

Yes
No

What was the outcome(s)?

Have you had fertility treatment before?

Which company did you have your treatment with?

Have you had any fertility blood tests before?

Yes
No

With which company?

Have you had a pelvic ultrasound?

Yes
No

With which company?

Do you have any personal history of endometriosis?

Yes
No
Not Sure

Do you have a history of polycystic ovaries?

Yes
No

Are your periods regular (beginning every 21-38 days)?

Yes
No
Third Choice

Male Partners

Previous children or pregnancies?

Yes
No

Previous abnormal semen tests?

Yes
No
Unsure

The fees charged in this practice exceed the Medicare Benefit Schedule (MBS) fee. Patients who require hospital procedures will be provided with informed financial consent. Payment on the day of consultation is expected. Non payment of accounts will result in your account being forwarded for debt collection by an external agency. Any fees incurred in collection of accounts will be passed onto the patient.

All personal information is handled in accordance with the practice’s privacy policy and consistent with the privacy legislation.

Dr Thomas is involved in teaching other specialists and gynaecologists in training. Occasionally de-identified clinical material including digital images obtained in surgery may be used.

I have read and understand the above arrangement of fees.*