Patient Information Form - Avonlea Clinic

Doctor to consult with*
Title
Name*
First Surname
Gender
Preferred Pronouns
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home phone
Work phone
Mobile phone*
Consent to be contacted via SMS*
Email*
Consent to be contacted via email*
Have you been fully vaccinated against COVID-19?*
- Yes
- No
Do you agree to have a medical student sit in on your consultation?*
- Yes
- No

Note: Please enter 'Nil' if question doesn't apply.
Past surgery*
Medical problems*
Mental health problems*
Periods*
Bladder problems*
Bowel problems*
Pregnancies, Births*
Last Cervical Screening test (PAP)*
Family history*
Medications and Supplements*
Allergies*
Smoke? Drink alcohol? Any others?*
Contraception?*
*
First Last
Consent*
I agree*
I give my permission for my medical records to be obtained from or sent to any specified doctor and or medical institute. I give consent for my doctor to submit their account for my surgical procedure to my health fund on my behalf. I hereby agree to pay all costs incurred for my care and treatment by my doctor.