Dr Poonam Arora

Dr Iruka Kumarage

62 Gloucester Avenue, Berwick VIC 3806

Ph: 9769 3223

Fax: 9769 7224

E: reception@ewobgyn.com.au

Patient Registration Form

PATIENT DETAILS

Appointment For

First Name *

Last Name *

Date of Birth *

Mobile Phone *

Email *

Address

City / Suburb

State

Postcode

EMERGENCY CONTACT DETAILS

Name *

Mobile Phone *

Email

REFERRING DOCTOR TO US

Referring Doctor’s Name *

Clinic Name *

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

Clinic Name

MEDICARE

Do you have a Medicare Card? *

YesNo

Medicare Card Name *

Medicare Card No. *

Reference No. (Number next to your name) *

Expiry

*If you do not have a Medicare card, please enter zeros as you will not be permitted to proceed if this field is left blank.

PRIVATE HEALTH INSURANCE

Do you have Private Hospital Cover *

Yes No

Have you had your private hospital cover for over 12 months?

Yes No

Provider

Membership No.

Expiry

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA No.

ULTRASOUND & PROCEDURE CONSENT

During the course of your consultation the doctor may require you to undergo a vaginal / pelvic examination, a procedure wherein swabs or biopsies may be taken or IUD's may be removed or inserted. This provides more information which will assist in the diagnosis and your treatment plan. Some of these may or may not be applicable to your visit with the doctor.

Potential examinations and procedure that may occur:

- Colposcopy examination

- Transvaginal examination

- Speculum examination

- Vaginal examination

- Pelvic ultrasound

You are under no obligation to have the examination or procedure performed and it will only be performed with your consent. If at any stage during the examination, you feel uncomfortable or do not wish to continue, please let the doctor know and the examination will be terminated immediatley.

If you have any questions or concerns; please address the doctor prior to or during the consultation.

The Procedure has been explained to me; I understand the following:

- Strict sterile techniques and instruments will be enforced.

- During a transvaginal scan the ultrasound trasnducer will be inserted into my vagina and the doctor will moved the transducer during the procedure to obtain the required images.

- I may request a third party to be present during the examination to act as a chaperone.

- The examination may not always provide a better quality image.

- The doctor will move the instraments during the examination or procedure to obtain the required swabs or biopsies.

- I may request for the examination to be stopped at any time during the procedure.

I consent for the examination or procedure to be performed *

Yes No

I am allergic to latex *

YesNo

Name: *

Signature: *

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SIGNATURE

I understand that this practice uses the following methods of communication to manage my care. Telephone , SMS , Email and Post.
*

I agree to the practice collecting and handling my personal information with care (which is available upon request).

I understand that this clinic has the right to collect my information for the primary purpose of providing quality health care.

*

I understand that I am responsible for any fees that are required for the health care of this clinic. Any fees associated are payable on the day.
*

I agree that payment of my account is due at the time of my consultation.
*

I agree that if I miss my appointment/s without notice to the practice within a 24 hour period there will be a cancellation or missed appointment fee.

*

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

I agree that if I do not have a Medicare Card that ANY telehealth appointments carried out will incur a $15 out of pocket cost.
*

Patient/ Guardian Signature *

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