Make an Appointment

In order to make an appointment and claim Medicare benefits you will need a referral from a medical practitioner. Your referring doctor can send the referral by email, post or fax.

Bring your referral to your consultation along with any Xray reports, films, CDs, current medication list and copies of lab tests. Please fill out the patient questionnaire below online and send to us prior to your appointment.

PATIENT DETAILS

Name *

DOB *

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Phone Number *

Email *

Private Health Fund

Pension Details (Type)

Type of Patient

• Private
• Public
• DVA

REASONS FOR REFERRAL

Reasons for Referral

• Investigation of Haematuria
• Prostate cancer / Abnormal PSA
• Renal Stones
• Bladder outlet obstruction or prostate enlargement
• Incontenence
• Lower urinary tract infection
• Peno-scrotal condition
• Uro-gynaecology

INVESTIGATIONS PERFORMED

Investigations Performed

• FBC
• FBC Results Included
• U and E
• U and E Results Included
• PSA
• PSA Results Included
• MSU
• MSU Results Included
• USS renal tract
• USS renal tract Results Included
• CT abdo
• CT abdo Results Included

PRIVATE AND CONFIDENTIAL MEDICAL QUESTIONNAIRE

Private and Confidential Medical Questionnaire

• Rheumatic fever
• High blood pressure
• Bleeding tendency
• Joint replacement
• Spinal injury
• Hepatitis
• Radiation therapy
• Do you have HIV or AIDS
• Diabetes
• Asthma
• Epilepsy
• Thyroid Disease
• Stomach Ulcer
• Jaundice or Liver Disease
• Drug Allergy (e.g. penicillin and sulphur drugs)
• Other Allergies (e.g. shellfish, eggs, antiseptics, latex)
• Do you react to intravenous contrast? (dye injection)
• Nervous System Disorder
• Stroke
• Do you smoke?

If yes, how long?

How many per day?

What medication(s) are you taking?

Have you had any past operations?

REFERRED BY

Name

Address

Phone

Return Correspondence by

• Post
• Email

Photo of the referral (if available)

Click or drag a file to this area to upload.

DECLARATION

By submitting this form I acknowledge that this is an accurate medical history and I understand that this information will be treated with complete medical confidentiality and will only be shared with other health personnel involved in my care.

Date *

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Declaration *

• I understand the above declaration and wish to submit this form

Submit