Patient Details

Surname*

Given Names*

Address*

Date of Birth*

Phone (daytime)*

Mobile*

Email*

Billing Details

Medicare Details*

Medicare Reference Number*

Medicare Expiry Date*

Do you have private health insurance?*

YesNo

Referring Doctor

Doctor's Name*

GP Name & Address*

Partner Details

Surname*

Given Names*

Date of Birth*

Mobile*

Patient History

Have you previously attended The Royal Women's Hospital or had IVF treatment at another clinic?*

YesNo

Privacy Statement & Consent

In order to provide you with the highest standard of care, I will ask for personal information from you. This information covers basic details such as your name, address and telephone number but it is also necessary to know about your general health and past medical or surgical events. Without this general health picture, I am unable to plan your care properly.

Naturally some of this information is of a personal nature and some of it might be regarded as ‘sensitive’ and not the sort of information that you would wish to be necessarily disclosed to others.

We value the need to safeguard this information, and in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Medical Association, we would like to assure you that:

• I understand that the information collected will only be used to individualise and optimize my care.
• I understand that it may sometimes be necessary to disclose some information to other doctors and health professionals involved in my care. They are also bound by the same privacy obligations.
• My health information will not be disclosed to anyone not associated with your treatment, without my express consent.
• I may seek access to the information held about me and we will provide this access without undue delay.

Consent*

I acknowledge that I have read, understood and agree to the privacy consent.