Booking Form

Please provide the following information if you would like to make a booking. We will need to speak with you via telephone to finalise the details and your booking.

Family Name (required)

Given Name (required)

Date Of Birth

Address

Phone (required)

Email

Medicare Card Number

Health Care Card Number (if you have one)

Private Health Insurance Details (if you have it)

Emergency Contact Name

Emergency Contact Phone

Booking Day and Location Preference:
Tuesday afternoon (Werribee)Wednesday afternoon (Werribee)Thursday afternoon (Werribee)Friday Morning (St Albans)Friday Afternoon (St Albans)

Preferred Date:(we will call to confirm date availability)

Questions or Other Information?

Patient Information

What is your preferred Language:

Interpreter required? YesNo

Do You Take Medication? Please list (Medication, Dose, How often):

What was the first day of your last menstrual period:

Is your cycle regular?
YesNo

Gestation

How was pregnancy confirmed?
Home Urine TestAt the DoctorUrine TestBlood TestUltrasound

If Home Urine Test - date

If Ultrasound - date & location

(Please bring a copy of the result, or have it faxed to 03 9769 4447)

Are you currently breast feeding? YesNo

Have you had any pregnancies before? YesNo

If yes - Abortions (How Many), Miscariages (How Many), Vaginal Deliveries (How Many), C Sections (How Many):

DO YOU HAVE ANY ALLERGIES? YesNo
List

What is the Reaction?

LATEX REACTION?
YesNo

Do you have swelling of mouth or tongue or any breathing difficulties?

Height:

Weight:

Blood Group: If you have a blood group card bring it with you

MEDICARE: If you do not have an Aust. Medicare card, or Private Health Insurance, and you have any tests done, Pathology will bill you directly for those tests. These charges are NOT from The Women’s Clinic.
Pathology costs if no insurance or Medicare card: Approx $100

Do you want (tick appropriate one): Intra-uterine device: MultiloadMirenaImplanonDepoprovera injection
Pap Test? YesNo

Do you need a : Medical Certificate:YesNo | Carers Certificate:YesNo

Medical & Surgical History (Any Asthma, Heart Problems, Epilepsy, Hepatitus, Blood Pressure, Kidney, Depression, Burst Appendix etc.)

Do you Smoke, Drink or take Drugs? (State what and how many/often):

Family History (Heart Disease, Diabetes, Cancer of breast or uterus)

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