New Patient Form

Welcome to Wellend Health

Thank you for taking the time to complete this form. Your responses help us prepare your patient file before your appointment.

Important Note:

This form is for patients who have already booked their first appointment. If you have not yet scheduled your appointment, please contact our clinic first, either by email or phone to arrange a suitable time before completing this form.

If you’re unsure or need assistance, our friendly team is happy to help.

- Have your Medicare and private health insurance details ready.
- Answer all questions as accurately as possible
- If a question does not apply to you, simply leave it blank or you can mark it as N/A (Not Applicable)
- Required fields are marked with an asterisk (*) and must be completed before moving to the next page.
- If you are unable to proceed, check for any fields highlighted in pink—these need to be completed before continuing.
- You will have a chance to review your answers before submitting the form.

It's not required but should you have additional medical information that you would like to share with your doctor, please contact our clinic. We can provide a secure link for you to upload documents directly into your patient file.

If you need any assistance, our team is happy to help
STEP 1

Patient details
Title:
First name:*
Last name:*
Preferred name:
Date of birth:*
Date Format: DD slash MM slash YYYY
Posal Address
Address 1:
Address 2:
Suburb:
State:
Post Code:
Residential Address (if different from address above:)

Your Doctor will need a residential address on file should you require any electronic scripts during your care.
Address 1:
Address 2:
Suburb:
State:
Post Code:
Home Phone:
Work Phone:
Mobile Phone:*
Emergency Contact
Name:
Relationship:
Phone Number:

STEP 2
Your e-mail address
We like to communicate with our patients via email for clinical notifications. We will not give your email address out to anyone and it will only be used for "Wellend business".
Email address:*
Email Address: Confirm (re-type) your email address:

STEP 3
Doctor Details
If you have a GP, then: GP Name:
Location of the practice you attend:
Please enter name(s) and location(s) of any other doctors you would like sent your results:
Insurance Details
Medicare No:*
Name and number next to your name on Medicare card:*
Department of Veteran's Aﬀairs (DVA) Card Number:
Colour of DVA Card (if applicable):
Insurance Details

Please note that all consultations with our Medical Doctors and Specialists incur a fee, as we are a private practice. Unfortunately, we do not offer bulk billing or concession rates. However, we kindly request the following details, as they may be required for test request forms and other aspects of your future care.
Please complete if any of the following is applicable:
Private Health Fund (if applicable):
Private Health Fund Membership No (if applicable):
Concession Card Details (if applicable):

STEP 4
Reason for visit
Please tick any box that applies*
- Breast Cancer Prevention - High Breast Density
- Hormonal Dysfunction
- Pelvic Pain, Contraception, or other female concerns
- Other
If other, then please specify reason

STEP 6
Medicinal Information
Are you allergic to any medication?*
- Yes
- No
If yes, then name of medication(s) and reaction(s) caused:
Are you currently taking any prescription medication?*
- Yes
- No
If yes, then please list medication name, strength or dosage, and frequency:
Are you currently taking any NON-prescription medication, including herbal suppliments?*
- Yes
- No
If yes, then please list:

Covid-19 vaccination status details Please note our Doctors here at Wellend Health would like to ask you if you are comfortable in providing us with your Covid-19 vaccination details and ask are you currently vaccinated for Covid-19?
COVID-19 Vaccination Status*
Other

STEP 7
End of the patient form
Thank you very much for taking the time to fill out this questionnaire, and know that we look forward to seeing you soon.

If you would like to review your answers before you send it, please click the previous step button below, or alternatively, click the numbers circles above.

When you are happy, click submit button below.
Privacy of Information Authority
Privacy of Information Authority
I consent to Wellend Health Pty Ltd (ACN 161 970 396) collecting personal information relevant to my health and treatment and sharing this information with health care providers involved in my care. If you do not agree to Wellend Health Pty Ltd sharing your personal information across its affiliated health providers and other health professionals, we may be unable to provide services to you or we may be limited in the type or quality of services that we provide to you. All personal information is handled in accordance with relevant privacy legislation. I give my permission for my de-identified information to be used in research, development and commercialization of new medical therapies and devices as well as quality assurance purposes. I have read, and understood and have agreed to the above Privacy of Information Authority Statement.
I consent to Wellend Health Pty Ltd (ACN 161 970 396) collecting personal information relevant to my health and treatment and sharing this information with health care providers involved in my care. If you do not agree to Wellend Health Pty Ltd sharing your personal information across its affiliated health providers and other health professionals, we may be unable to provide services to you or we may be limited in the type or quality of services that we provide to you. All personal information is handled in accordance with relevant privacy legislation. I give my permission for my de-identified information to be used in research, development and commercialization of new medical therapies and devices as well as quality assurance purposes. I have read, and understood and have agreed to the above Privacy of Information Authority Statement.
*
- I agree

New Patient

Welcome to Wellend Health

Important Note:

Patient details

Posal Address

Residential Address (if different from address above:)

Emergency Contact

Your e-mail address

Doctor Details

Insurance Details

Insurance Details

Reason for visit

Medical Details

Relevant Medical History

Medicinal Information

End of the patient form

Privacy of Information Authority