RODGERS – New Patient form

  • New Patient Registration Form

  • Reason for appointment? *
  • Date of Birth*
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  • Current date
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  • Do you have a Medicare card?*
  • Do you have private health insurance?*

  • COVID-19

  • COVID-19 symptoms include:
  • Possible COVID-19 exposures include:
    • Partner 1: Consent for Release of Medical Information to Partner 
    • *
    • Date
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    • About your partner…

    • Date of Birth*
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    • COVID-19

    • COVID-19 symptoms include:
    • Possible COVID-19 exposures include:
    • Partner 2: Consent for Release of Medical Information to Partner 
    • *
    • Date
       - -

  • GP Details

  • *Please note – in order to be able to claim the Medicare rebate for your consultation, you will need to provide us with a referral by a GP or medical specialist addressed to Dr Rachael Rodgers.

  • Fertility Investigations

  • Have you or your partner undertaken any of the following investigations that might be of value during your consultation?

  • Date
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  • Date
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  • Date
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  • Date
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  • Date
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  • Have you previously had any fertility treatment?
  • How did you hear about Dr Rachael Rodgers? (tick all that apply)

  • Medical information

    (If attending as a couple, this information relates to the female partner requiring assessment/treatment)

  • Do you currently have or do you have a history of any of the following medical conditions?
  • Please specify the type of cancer:

  • Please specify the type of diabetes:
  • Please specify your current diabetes treatment:
  • Please specify type of liver disease:
  • Please specify type of stomach / gastric issues:
  • Do you smoke?*
  • Do you drink alcohol? If so, how many standard drinks would you consume in a week?*
  • Have you ever had a cervical screening test before?*
  • What was the result of your most recent cervical screening test?*

  • Have you ever had an abnormal cervical screening test result?*
  • Do you take any regular medications?*
  • Do you take any supplements or herbal medications?*
  • Have you had an allergic reaction or adverse reaction to a medication, other substance or treatment (eg. contrast used for CT scan)?*
  • Blood Clotting Risk Assessment (please tick any of the following that apply to you)*
  • Please specify the blood clotting disorder you have

  • Bleeding Risk Assessment (please tick any of the following that apply to you)*
  • Please specify the bleeding disorder you have

  • Please specify the bleeding disorder that your family members have

  • Immunosuppression Risk Assessment (please tick any of the following that apply to you)*
  • Please tick, if personal or family history has any of the following conditions:
  • Would you like us to provide you with information regarding pre-conception genetic screening tests available in Australia?*

  • This will allow you to review the material and ask any questions you have relating to this information during your consultation.

  • Collection of Personal lnformation, Privacy Act 1988 (Cth) and HRIP Act 2002 (NSW)

    Dr Rodgers' medical practice collects information from you for the primary purpose of providing tailored quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assist, diagnose and treat conditions and be proactive in your healthcare. We will also use the information you provide in the following ways:

    • Administrative purposes in running Dr Rodgers' medical practice (including lT providers)
    • Billing purposes, including compliance with Medicare and Health lnsurance Commission requirements
    • Disclose to others involved in your health care, including treating doctors and specialists outside of Dr Rodgers' practice
    • De-identified data analysis for the purpose of audit and researches

    Dr Rodgers’ medical practice uses AI software to assist with record taking and consultation notes. These recordings are not kept or stored after your consultation has been completed.

    I am aware that personal information may be sent and received electronically by Dr Rodgers' practice and, whilst the utmost care is taken to ensure correct transmission of information, I understand this may not be 100% secure.

    I have read the information above and the privacy policy and understand the reasons why my information must be collected. I understand I am not obliged to provide any information requested of me, but that my failure to do so may compromise the quality of health care and treatment given to me.

    I am also aware of my right to access the information collected about me, except in circumstances where access might be legitimately 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 fees for time spent and administrative costs, which may not be covered by a Medicare rebate.

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

    I understand to the handling of my information by Dr Rodgers' practice for the purposes set out above, subject to any limitations on access or disclosure that I notify in writing to this practice.

  • Date
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  • Should be Empty: