Self Referral Form

Self Referral Form

New Patient Registration and Health Questionnaire
Patient Registration
Welcome to ERH Associates and thank you for completing this form.

Please complete this form so our clinical team has the information needed to review your referral or appointment request.

This form helps us understand what you are seeking help with, your relevant medical history, current medications, symptoms, and what you are hoping to get from an appointment.

Please note: this form collects clinical information only. If we need to proceed further, you will receive a separate email asking you to complete ERH Associates’ online registration. This collects your formal registration details, consents and Terms and Conditions.

Completing this form does not mean an appointment has been booked. Once your information has been reviewed, our admin team will contact you with the outcome and any suitable appointment options. This may include information about the recommended appointment type, available providers, fees, insurance, and next steps.

ERH Associates is not an urgent care service. If you have urgent symptoms or need immediate medical advice, please contact your GP, Healthline, an urgent care clinic, or emergency services.

Please complete this form as accurately as you can. If anything important changes after you submit it, please let us know.
NHI Number (if known)
Date

DayMonthYear
Date
Patient Name

First NameLast Name
Signature (if patient is under 16, a guardian must sign)
Fees For Appointments

Fees and payment

ERH Associates is a private healthcare provider and fees apply for appointments and some services.

If an appointment is offered, we will confirm the appointment type, provider, fee, payment or deposit requirements, insurance information, and next steps before your appointment is booked.

I understand that fees may apply if I proceed with an appointment or other ERH Associates services.
I have read and understood the fee structure and accept responsibility for payment.
About You
Patient Name

First NameLast Name
Preferred Name
Previous Names
Gender
Pronouns
e.g she/her, he/him, they/them
Date of Birth

DayMonthYear
Date
Email
example@example.com
Mobile Phone Number
Is the patient younger than 16
Parent Name

First NameLast Name
Phone Number
Insurance Information (if no insurance please write None, N/A)

Insurance CompanyPolicy Number
Emergency Contact

First NameLast Name
Relationship
Phone Number
Health Questionnaire
Reason(s) for seeing a specialised women's health GP /anything in particular you would like to get out of the appointment? Please give as much detail as you can.
Medical History
List any diagnoses, illnesses, surgeries:
Do you get migraines?
Do you get visual or neurological symptoms with the headaches?
Medications

Current medications (both prescription and over the counter including supplements and herbal remedies), please list:

Medications

Rows	Medication	Dosage	When Started	Last Dose Change
1
2
3
4
5
6
7
8
9
10

Have you used hormonal contraception previously?
Which type?
Do you have any allergies or reactions to any medication?
Please Specify
Family History
Have any family members had breast cancer or ovarian cancer?
relationship and approximately what age were they?
Have any family members had heart attacks, angina or strokes?
relationship and approximately what age were they?
Has anyone had osteoporosis in the family?
relationship and approximately what age were they?
Has anyone had hip fractures in the family?
relationship and approximately what age were they?
Has anyone had a blood clot(deep vein thrombosis or pulmonary embolism) in the family
relationship and was there any genetic or other cause found?
Are there any autoimmune conditions that run in your family?
Please Specify
Anything else that particularly runs in the family?
Biometrics
Is your blood pressure usually normal?
Height (cm's)
Weight (kg's)
Have you ever been overweight or underweight?
Has your weight been changing or stable recently?
Social History
What sort of work/study/daily activities do you do?
Have you ever smoked?
How long, how many per day
Do you drink alcohol?
How many drinks/how often:
Who lives with you at home?
What exercise do you do?
How is your diet? (do you eat regular meals/snacks, do you avoid any food groups (eg. dairy, meat, gluten etc)
Further Questions (if applicable)
How old were you when you got your first period?
What is your current cycle like?
Have your periods ever been irregular, heavy, excessively painful, excessively heavy or associated with severe PMS or headaches?
Do you have children?
How Many?
Any other pregnancies?(miscarriages, terminations)
Have you had any issue with fertility delay?
Any additional medical history you would like us to know?
Declaration and next steps

Thank you for completing this form.

By submitting this form, you confirm that the information you have provided is true and correct to the best of your knowledge. You also understand that it is your responsibility to let ERH Associates know if your symptoms, medications, medical history, or other relevant information changes.

Please note that submitting this form does not mean an appointment has been booked. Your information will be reviewed by our team, and we will contact you by email with the outcome and any suitable appointment options.

If an appointment is offered, we will confirm the appointment type, provider, fee, payment or deposit requirements, insurance information, and any next steps before your appointment is booked.

If needed, you will also receive a separate email asking you to complete ERH Associates’ online registration before an appointment can be confirmed. This collects your formal registration details, consents and Terms and Conditions.

ERH Associates is a private healthcare provider and fees apply for appointments and some services. Payment and insurance requirements will be confirmed as part of the booking process.

If your symptoms change or you need urgent medical advice while waiting to hear from us, please contact your GP, Healthline, an urgent care clinic, or emergency services.
I confirm that I have completed this form as accurately as possible and understand the next steps outlined above.
Should be Empty:

Self Referral Form

Patient Registration

About You

Health Questionnaire

Medical History

Medications

Family History

Biometrics

Social History

Further Questions (if applicable)