Form test

Patient Registration Form

Step 1 of 14

Preferred gynaecologist(Required)

Do you have an appointment booked with the abovementioned Specialist?(Required)

Yes

If you check "Yes" and do not have an appointment booked, your form will not be processed.

Have you provided the Rooms with a current referral?(Required)

Yes

If you check "Yes" and have not provided the Rooms with a current referral, your form will not be processed.

Unfortunately we are unable to process your information at this time.

Please note that that in order to complete this form you must have provided the Rooms with a current referral, allowing us to book you an appointment. In the previous question(s) you indicated you have not provided the Rooms with a current referral, and/or have not scheduled an appointment. Please complete these steps before completing this form.

Name(Required)

Title Given name Family name

Date of birth(Required)

DD slash MM slash YYYY

Personal Pronouns

Home address(Required)

Street Address Address Line 2 City Post code

Home phone number

Mobile phone number(Required)

Email address(Required)

Occupation(Required)

Emergency contact name(Required)

Given name Family name

Emergency contact's phone number(Required)

Emergency contact's relation to patient

Is your next of kin the same as your emergency contact?

Yes

Next of kin contact name(Required)

Given name Family name

Next of kin's contact phone number(Required)

Next of kin's relation to patient

Healthcare details

Medicare number (10 digits)

Card reference number

Card expiry date

DD slash MM slash YYYY

Do you have private health insurance?(Required)

Yes

Please note that this Practice will only see patients with current private health insurance and hospital cover.

Please select that which applies:(Required)

Please note that this Practice will only see patients with current private health insurance and hospital cover.

Unfortunately we are unable to see you

Please note that this Practice will only see patients with current private health insurance and hospital cover. In the previous question(s) you indicated you do not currently have private health and/or hospital cover, therefore you are unable to complete and submit this form. If you have questions regarding this please contact our Rooms.

Health fund name(Required)

Member number(Required)

Have you been with your health fund for more than 12 months?(Required)

Yes

Is the patient responsible for this account?(Required)

Yes

Account holder's name(Required)

Given name Family name

Account holder's relationship to patient(Required)

Account holder's phone number(Required)

GP's details(Required)

Title Given name Family name

Please ensure your referral has been forward to our Rooms. Your referral must be current to obtain a Medicare rebate.

GP's address(Required)

Street Address Address Line 2 City State / Province / Region Postcode

Patient History

Please list your medical history including any previous surgeries

Please list current medications, including over-the-counter medications and supplements (e.g., fish oil)

Do you have any allergies, including non-drug allergies?(Required)

Yes

Please list allergies

Height (m) E.g., 179cm = 1.79(Required)

This information is required for surgical procedures. If you are unsure please estimate to the best of your abilities, and inform staff at your initial consult.

Weight (kg) E.g., 85(Required)

This information is required for surgical procedures. If you are unsure please estimate to the best of your abilities, and inform staff at your initial consult.

Body Mass Index (BMI = kg/m²)

E.g., 85 / 1.79² = 26

Create a Privacy Password

This is used to identify you when discussing private medical information by phone.

Mother's Maiden Name(Required)

First Pet's Name(Required)

Prior to your appointment

To ensure you get the most out of your appointment, and can maximise time spent discussing your issue with Dr Pontré, please complete this form prior to your appointment. Please note that you will be required to discuss these responses during your consult. If you would prefer to complete a hard copy, you are able to download the form at the end of this page. If this is your preference, please ensure you scan and email the completed form to reception@drjenniferpontre.com.

A copy of my most recent ultrasound scan and CST has been sent to reception@drjenniferpontre.com.au.(Required)

I agree

If your most recent CST was abnormal, please ensure the Rooms have received a copy of your last three CSTs.

Have you previously had surgery with another gynaecologist that you would like to discuss at your appointment?(Required)

Yes

A copy of any relevant previous operation reports have been sent to reception@drjenniferpontre.com.au(Required)

I agree

General

What is the main issue that you would like to discuss at your appointment? If multiple, please list.(Required)

E.g., heavy bleeding, pain, abnormal cervical screening test.

Pregnancies

Have you previously been pregnant?(Required)

Yes

Number of pregnancies:(Required)

How many births have you had via VAGINAL delivery?(Required)

How many births have you had via CAESAREAN?(Required)

Periods

Do you have periods?(Required)

Yes

What was the date of your last period?(Required)

DD slash MM slash YYYY

Is your cycle:(Required)

Regular

Irregular

How many days do you typically bleed for?(Required)

How many days is your typical cycle?(Required)

Are your periods painful?(Required)

Yes

Do you experience pain between your periods?(Required)

Yes

Do you experience bleeding between your periods?(Required)

Yes

Cervical Screening Tests (CSTs)

Have you ever had a CST?(Required)

Yes

What was the date of your most recent CST?(Required)

DD slash MM slash YYYY

The result of this CST was:(Required)

Normal

Abnormal

Have you had a Gardasil injection (HPV vaccine)?(Required)

Yes

Medical History

Please list your medical conditions:(Required)

Please list your previous surgical procedures:(Required)

Please list in order of most to least recent.

Please list prescribed and over-the-counter medications that you are currently taking:(Required)

E.g., fish oil.

Please list each of your allergies, in addition to the reaction you typically experience.(Required)

Please detail any family medical history you are aware of:(Required)

Contraception

Are you currently using any form of contraception?(Required)

Yes

What form of contraception do you currently use?(Required)

Lifestyle

Do you drink alcohol?(Required)

Yes

Do you smoke or vape nicotine?(Required)

Yes

In a typical week, how many standard drinks do you consume?(Required)

In a typical week, how many cigarettes do you consume?(Required)

Patient Information(Required)

FEES: This is a PRIVATE billing practice and Dr Karthigasu's fees are charged based on AMA recommendations. Please also note that you will be privately billed for Telehealth consultations.

Appointment type	Approximate cost
First consultation	$280.00
First consultation endometriosis and long appointment	$300.00
Follow-up consultation	$150.00
Second Opinion	$330.00
Colposcopy (if needed)	$280.00
Biopsy (if needed)	$182.00

Payment is required at the end of each consultation. These accounts are claimable from MEDICARE. These fees are subject to increase every November.

Failure to attended an appointment without having cancelled with the rooms at least 24 hours prior may attract a $50 fee which is not claimable from MEDICARE.

PATHOLOGY
If you have a cervical screening test, biopsy or other type of pathology carried out at the time of your appointment you will receive a separate bill in the mail from the PATH WEST DEPARTMENT. They are totally separate accounts and should be paid separately.

REFERRALS
Your referral from your general practitioner to this centre is usually valid for 12 months. If you are referred by a specialist, this referral is only valid for 3 months. Medicare requires you to have a valid referral to be able to claim your full refund. It is your responsibility to ensure you have a valid referral.

I have read, understood and agree to the above information

Consent(Required)

PRIVACY ACT 1988: TO COLLECT & DISCLOSE INFORMATION

The Privacy Act 1988 requires medical practitioners to obtain consent from their patients to collect, use and disclose that Patient’s personal information.

Collection
This means we will collect information that is necessary to properly advise and treat you. Such necessary information may include:

• Full medical history
• Family medical history
• Ethnicity
• Contact details
• Medicare/private health fund details
• Genetic information, and
• Billing/account details

The information will normally be collected directly from you. There may be occasions when we will need to obtain information from other sources, for example:

• Other medical practitioners, such as former GPS and Specialists  
• Hospitals and Day Surgery Units, and  
• Other health care providers such as  physiotherapists, occupational therapists, psychologists, pharmacists, dentists, nurses.

Both our practice staff and the medical practitioners may participate in the collection of the information.  

In emergency situations we may need to collect personal information from relatives or other sources where we are unable to obtain your prior express consent.  

Use and Disclose
With your consent, the practice staff will use and disclose your information for purposes such as:  

• Account keeping and billing purposes
• Referral to another medical practitioner or health care provider
• Sending of specimens, such as blood samples or cervical screening test for analysis
• Referral to a hospital for treatment and/or advice
• Advice on treatment options
• The management of the practice
• Quality assurance, practice accreditation and complaint handling
• To meet our obligation of notification to our medical defence organisation or insurers
• To prevent or lessen a serious threat to an individual’s life, health or safety, and
• Where legally required to do so, such as producing records to court, mandatory reporting of child abuse or notification of diagnosis of certain communicable diseases.

Access
You are entitled to access your own health records at any time convenient to both yourself and the practice.

Access can be denied where: 
• To provide access would create a serious threat to life or heath
• There is a legal impediment to access
• The access would unreasonably impact on the privacy of another
• Your request is frivolous
• The information relates to anticipated or actual legal proceedings and you would not be entitled
to access the information in those proceedings* • In the interest of national security.

We ask that, where possible, your request be in writing. We may impose a charge for photocopying or for staff time involved in processing your request. Where you dispute the accuracy of the information we have recorded you are entitled to correct that information. It is our practice policy that we will take all steps to record all of your corrections and place them with your file but will not erase the original record.

I have read, understood and agree to the above information

Patient information(Required)

FEES: This is a PRIVATE billing practice. Please also note that you will be privately billed for Telehealth consultations.

Appointment type	Approximate cost
First consultation	$280.00
First consultation and long appointment	$300.00
Follow-up consultation	$160.00
Second Opinion	$300.00
Colposcopy	$160.00 + consultation fee
Vulval biopsy	$150.00 + consultation fee
Cervical biopsy	$160.00 + consultation fee
Mirena	$150.00 (in our Rooms) + consultation fee

Payment is required at the end of each consultation. These accounts are claimable from MEDICARE. These fees are subject to increase every November.

Failure to attended an appointment without having cancelled by calling or emailing the rooms at least 24 hours prior may attract a $50 fee which is not claimable from Medicare.

PATHOLOGY
If you have a cervical screening test, biopsy or other type of pathology test carried out at the time of your appointment you will receive a separate bill in the mail from the PATH WEST DEPARTMENT. These are totally separate accounts and should be paid separately.

REFERRALS
Your referral from your general practitioner to this centre is usually valid for 12 months. If you are referred by a specialist, this referral is only valid for 3 months. Medicare requires you to have a valid referral to be able to claim your full refund. It is your responsibility to ensure you have a valid referral.

I have read, understood and agree to the above information

Consent(Required)

COLLECTION OF PERSONAL INFORMATION, PRIVACY ACT 1988

We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below.

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose and treat illnesses and be pro-active in your health care. We will also use the information you provide in the following ways:

• Administrative purposes in running our medical practice

• Billing purposes, including compliance with Medicare and Health Insurance Commission requirements

• Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals. If necessary, we will discuss this with you.

• Disclosure to other doctors in the practice, locums and by Registrars attached to the practice for the purpose of patient care and teaching. Please let us know if you do not want your records accessed for these purposes, and we will note your record accordingly.

• Disclosure for research and quality assurance activities to improve individual and community health care and practice management. You will be informed when such activities are being conducted and given the opportunity to "opt out" of any involvement

I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information.

I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.

I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if I request access to information about me, the practice will be entitled to charge me fees to cover

• time spent by administrative staff to provide access at the employee’s hourly rate of pay

• time necessarily spent by a medical practitioner to provide access at the practitioner’s ordinary sessional rate and

• for photocopying and other disbursements at cost

I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.

I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.

I have read, understood and agree to the above information

Patient information(Required)

FEES: This is a PRIVATE billing practice and Dr Pontré's fees are charged based on AMA recommendations. Please also note that you will be privately billed for Telehealth consultations.

Appointment type	Approximate cost
First consultation	$280.00
First consultation and long appointment or Endometriosis	$300.00
Follow-up consultation	$160.00
Second Opinion	$300.00
Colposcopy	$160.00 + consultation fee
Vulval biopsy	$150.00 + consultation fee
Cervical biopsy	$160.00 + consultation fee
Mirena	$150.00 (in our Rooms) + consultation fee

Payment is required at the end of each consultation. These accounts are claimable from MEDICARE. These fees are subject to increase every November.

Failure to attended an appointment without having cancelled by calling or emailing the rooms at least 24 hours prior may attract a $50 fee which is not claimable from Medicare.

PATHOLOGY
If you have a cervical screening test, biopsy or other type of pathology test carried out at the time of your appointment you will receive a separate bill in the mail from the PATH WEST DEPARTMENT. These are totally separate accounts and should be paid separately.

REFERRALS
Your referral from your general practitioner to this centre is usually valid for 12 months. If you are referred by a specialist, this referral is only valid for 3 months. Medicare requires you to have a valid referral to be able to claim your full refund. It is your responsibility to ensure you have a valid referral.

I have read, understood and agree to the above information

Consent(Required)

I have read, understood and agree to the above information

Patient Registration Form

Unfortunately we are unable to process your information at this time.

Healthcare details

Unfortunately we are unable to see you

Patient History

Create a Privacy Password

Prior to your appointment

General

Pregnancies

Periods

Cervical Screening Tests (CSTs)

Medical History

Contraception

Lifestyle

Dr Robyn Leake

Dr Jennifer Pontré

Dr Krish Karthigasu