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Phone (03) 9516 5555
About Us
Fertility
Clinical Problems
Endosurgery
Book an Appointment
Contact
About Us
Fertility
Clinical Problems
Endosurgery
Book an Appointment
Contact
Book an Appointment
admin
2018-03-05T16:41:13+10:00
Providing professional care in fertility, gynaecology and minimally invasive surgery
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Patient Registration
Name
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First
Last
Salutation
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Dr
Mr
Mrs
Ms
Miss
Preferred Name
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Date of Birth
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DD slash MM slash YYYY
Height
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Weight
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Do you smoke
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Yes
No
Previously
Email
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Address
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Post Code
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Occupation
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Marital Status
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Married
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Defacto
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Separated
Same Sex
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Mobile
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Phone (H)
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Phone (W)
Next of Kin/Partners Name
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Relationship
*
Partner Date of Birth
*
DD slash MM slash YYYY
Next of Kin/Partner Mobile
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Next of Kin/Partner Email
*
Partner Occupation
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Health Insurance Fund
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(HIF) Number
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Medicare Number
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Ref. Number (before your name)
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Next of Kin Medicare Number
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Next of Kin Ref. Number (before your name)
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Select as Appropriate
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Veterans Affairs
Pension
HCC
Expiry Date
Number
Referring Doctor
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Usual GP
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Please indicate any major illnesses or operations in the past
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Do you take any "blood thinners" eg Warfarin, Clopidogrel, Aspirin, Iscover?
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Yes
No
Please list other medications (including "natural therapies")
Please list any allergies
How did you find out about us?
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Web Search
GP Referral
Word of Mouth
Friend
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?
Null
IVF
IUI
Clomid or Serophene
Which company did you have your treatment with?
Null
Monash
Melbourne
City
Other or Interstate
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.
Copies of your results are automatically sent to My Health Record. Please activate the connection to your health record through MyGov. Visit the MyGov website for instructions on how to link your account so that you can receive your medical information.
I have read and understand the above arrangement of fees.
*
Yes
No
I acknowledge and have read the practice privacy and debt collection policies
*
YES
NO
Select a Date
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