headspace Armadale Clinic

headspace Armadale Clinic

PATIENT INFORMATION
PLEASE ONLY FILL OUT THIS FORM IF YOU ARE AGED 12-25. WE ARE UNABLE TO SERVICE ANYONE BELOW OR OVER THAT AGE RANGE.

ALL INFORMATION PROVIDED ON THIS FORM IS KEPT CONFIDENTIAL, AND IS USED TO ENSURE CORRECT INFORMATION IS PASSED ONTO THE SEXUAL HEALTH NURSE.
Full Name*

First NameLast Name
Chosen Name
Date of Birth*

MonthDayYear
Date
Age*
Gender Identity*
Pronoun*
Sex Assigned at Birth*
Aboriginal or Torres Strait Islander?*

YesNo
Are You a Traveller?*

YesNo
Country of Birth*
Year of Arrival in Australia?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is it okay to send letters to the above address?*

YesNo
Contact Number*

Area CodePhone Number
Is it okay to contact this number?*

YesNo
SMS/ Voicemail*

SMS YESSMS NOVoicemail YESVoicemail NO
Email*
example@example.com
Are you having any symptoms?*

YesNoUnsure
Are you coming in for anything relating to contraception?*

YesNo
How did you find out about the Sexual Health Clinic?*
We will give you a call, once we have recieved your form, to book in with the sexual health nurse for a time that suits you.
Thank you!

**PLEASE DO NOT GO TO THE TOILET BEFORE YOU SEE THE NURSE PRACTITIONER**
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We will give you a call, once we have recieved your form, to book in with the sexual health nurse for a time that suits you.