Confirm

Surname *

Given Names *

DOB *

Mobile Number *

Which WUMe location are you scheduled to attend? *

Are you able to attend your appointment on the scheduled date and time? Please note that cancellations less than 24 hours prior to the appointment time will incur a late cancellation fee.

YesNo

Thank you. Please select Submit to cancel your appointment.

If you want to re-schedule, please give us a call on (03) 9417 6788.

One visitor over the age of 18 may accompany you for your scan. Children can not attend. *

Please acknowledge.

Is this your first visit to WUMe? *

YesNo

Upload a copy of your referral

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Please upload a photo of your referral. Please also be sure to bring your referral with you when you come for your scan.

Street Address *

Suburb *

Post Code

Email Address

Medicare Number

Reference Number

Expiry Date

Emergency Contact

Emergency Contact Name *

Emergency Contact Number *

Allergies & Medications

Do you have any allergies or are you sensitive to drugs or dressings (e.g. Latex, Bandaids or other)?

YesNo

Allergies

Are you taking any medications?

YesNo

Medications

Patient Consent

Please confirm you have read and agree to our consent statement. If you do not agree, please give our reception a call on (03) 9417 6788.

Yes, I consent to the conditions described in the WUMe Consent statement.
Please see full Consent statement here. *

Ultrasound Consent

I consent to a vaginal ultrasound as part of my examination. If a vaginal ultrasound is of concern to you, please phone our reception to discuss.

Signature *

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Date *