Incontinence Treatment Suitability Check
Complete the questions to help the clinic assess your treatment suitability.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Height (cm)
*
Weight (kg)
*
Have you had any previous surgery for incontinence, for example, a sling, mesh or bladder repair?
*
Yes
No
How often do you leak urine?
*
Occasionally, a few times a month
A few times a week
Daily
Many times a day, most days
Do you wear a pad or liner for leakage?
*
No
Occasionally
Most days, for part of the day
All day, every day
Which clinic is closest to you?
*
Sydney (Drummoyne)
Melbourne (Kew)
Neither of these
Which state are you in?
*
Please Select
NSW
VIC
QLD
WA
SA
TAS
ACT
NT
Are you currently under treatment for any other significant health condition?
*
Yes
No
Please tell us a little more
Do you leak when you stand up?
*
Yes
No
Can you not feel or are you unaware when the urine leakage is happening?
*
Yes
No
I understand this is a suitability check and not a medical diagnosis, and that suitability for treatment is confirmed with Dr Mike Shenouda at consultation. I consent to Géniale contacting me about this enquiry.
*
I agree
Submit
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