Patient Registration

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 a WUMe practice? *

YesNo

Upload a copy of your referral

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Please upload your referral, or take a photo of it and upload that here. Select multiple files if required.

Which WUMe location will you be attending? *

Title

Surname *

Given Names *

Street address *

Post code

Suburb

Mobile phone *

Pronouns

Email Address

D.O.B *

Medicare number

Reference number

Expiry date

Emergency contact

Emergency Contact Name

Phone Number

Notifications

I require an extra copy of my report to be sent to:

Do you authorise the practice to send you SMS confirmations for future appointments?

YesNo

Allergies and Medications

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

YesNo

Please list allergies:

Are you taking any medications?

YesNo

Please list medications:

COVID-19

If you experience any cold or flu like symptoms, or if you test positive to COVID-19 in the days prior to your appointment, please contact us by phone to re-schedule.

Patient Consent

Please confirm you have read and agree with our consent statement.

Yes.

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