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Appointment Type

Appointment type

Obstetrics
Gynaecology
Fertility

Patient Details

Title

First Name *

Surname *

DOB *

Patient Address and Contact Details

Residential Address

Street

Suburb

State

Postcode

Postal Address (if different to above)

Street

Suburb

State

Postcode

Email *

Mobile (preferred) *

Work or Home

Medicare Information

Medicare Number

Reference #

Medicare Expiry

Expires Month (copy)

Expires Year (copy)

Patient Health Fund Details

Private Health Fund

Yes
No

Obstetrics cover

Yes
No

Private Health Fund company

Fund Number

Defence Personnel Only

Single Line ID Number

Emergency Contact

First Name of Emergency Contact

Surname of Emergency Contact

Emergency Contact Mobile Number

Relationship of Emergency Contact to Patient

Partner Details (for Fertility patients only)

Title

First Name

Surname

Email

Mobile

DOB

Medicare Number

Reference # on card

Expires

Expires Month

Expires Year

Transvaginal Ultrasound

A transvaginal ultrasound uses a probe inserted into the vagina to examine female reproductive organs. This type of ultrasound provides much more detailed pictures of the organs in the pelvis, particularly the uterus (including fallopian tubes and ovaries) when compared to ultrasound scanning of the pelvis from the lower abdomen.

If required, this procedure will be done with your consent and with a nurse/midwife chaperone present.

Please select one option below:

Transvaginal Ultrasound consent *

I consent to Transvaginal Ultrasound if deemed necessary in my treatment
I am unsure and would like to discuss this further with someone from the specialist practice

Schedule of Fees

A schedule of fees is provided to you upon enquiry or booking an appointment and sets out the fees that may be applicable in our rooms. In the event of the account being in default and referred to an external party for collection, the customer shall be liable for all resulting costs arising from the recovery, including commission which would be payable if the account is paid in full and legal costs including demand cost.

Please select one option below:

Schedule of Fees consent *

I have received and accept the Schedule of Fees and understand that payment is due at time of service or as otherwise arranged.

Health Information Collection and Use

As a patient of our specialist practice we require you to provide us with your personal details and full medical history, so that we may properly assess, diagnose, treat and be proactive in your health care needs. We aim to protect the privacy and secure storage of your health information.

Our Privacy Policy is available online at drdor.com.au, which includes information about the collection, use and disclosure of your health and personal information. We require your consent to collect personal information about you and to use the information you provide.

You can decline to have your health information used in all or some of the ways outlined in the Privacy Policy, but it may influence our ability to manage your health care to provide the best outcome for you.

Health Information Collection and Use *

I have read the Privacy Policy and understand the reasons why my information must be collected.

Dr David O'Rourke accepts Order of Australia Medal from Governor-General, David Hurley

Public and Private patients