New Patient Registration Form

Please complete complete your patient registration form below before coming to your consultation with A/Prof Alex Ades. You can also upload your referral and other relevant documents/results by accessing your Clinic to Cloud Patient Portal link you have received by Email or phone message. If you haven’t received your Patient Portal access yet, please contact us so we can do so.

Please Select

Name

First Name

Last Name

DOB

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile

Work Tel

Home Tel

Emergency Contact

Name

First Name

Last Name

Mobile

Relationship

Family Doctor

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Medicare/Pension/Concession/Private Health Insurance

Medicare Number

Reference Number

Valid to

Private Health Fund

Membership Number

Reference Number

Veteran's Affair Number

If Applicable

Veteran's Affair Card Colour

Private Health Fund Company

If Applicable

Private Health Fund Number

Reference Number

Pension/Concession Card

Your card must be brought to your appointment

Pension/Concession Card Number

Parent of Guardian (If Applicable)

Name

First Name

Last Name

Relationship

Same Address as Patient

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile

Patient Consent

Personal Information

I understand this practice is guided by the Health Services Act 1988 (Vic), the Privacy Act 1988 (Cth) (and its Australian Privacy Principles) and the Health Records Act 2001 (Vic) (and its Health Privacy Principles) and apply them to their relationship with patients, employees, students, and service providers. I understand my personal information is collected for the purpose of providing health care. Information collected include my full name, date of birth, address, contact details, Medicare and private health insurer, financial details, health and medical history, lifestyle history, family history, details regarding my current health issue and details regarding my treating doctors. I understand that my personal information may be disclosed to others involved in my health care, such as other treating doctors and specialists outside this medical practice. I understand that I am not obliged to provide any information requested of me, but my failure to do so may compromise the quality of the health care and treatment given to me. By selecting YES I understand that I am consenting to the handling of my information by this practice for the purposes set out above.

COVID-19 Risk

I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the WHO. I understand that COVID-19 is extremely contagious and it spreads by person to person. As a result, Federal and State Governments have recommended social distancing. I acknowledge that this clinic, its doctors and staff are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 while in the clinic and/or hospital. I acknowledge the risk and consent to having a face-to-face consultation and physical examination. I have been given the option to defer any of the above to a later date. However, I understand that by selecting YES I confirm that I am aware of all the potential risks and would like to proceed.

Fee Policy

I understand this clinic is not a bulk billing practice. Payment is required at the time of consultation and before any procedure or surgery. I understand that diagnostic imaging and pathology requests, if required, will be performed by other independent practices and I will be charged separately for those services. In case of having a procedure or surgery, I understand that my surgeon’s estimate fees do not include hospital charges and services provided by other doctors, surgical assistants, anaesthetists, radiologists, etc. I understand that by selecting YES I acknowledge and agree to the fee policy above.

Today's Date

New Patient Registration Form

Endometriosis

Fibroids

Polyps

Cervical Insuficiency

Heavy Periods

ovarian cysts

Pelvic Organ Prolapse

Urinary Incontinence

Hysteroscopy

Laparoscopy

Hysterectomy

Myomectomy

Hysteroscopic Resection of Fibroids

Oophorectomy

Ovarian Cystectomy

Treatment of Endometriosis

Laparoscopic Transabdominal Cerclage

Endometrial Ablation

Patient Information

Contact