Fertility Specialists of WA – Electronic Registration

Registration Form
 
Fertility Specialists of Western Australia welcomes you as a new patient. Please take the time to fill out this registration form as accurately as possible. This information will help us to prepare in advance for your treatment and provide you with personalised care.

It is important that we receive a completed registration form so we can send out your Individualised Patient Information Pack.


Confidentiality


We understand the importance of protecting your personal information and have security measures in place to ensure the information submitted is treated as private and confidential as per our Privacy Collection Statement and Privacy Policy and the Terms and Conditions of this website.

If you need more information please contact our friendly staff to discuss any questions you may have.

We are here to help.


Please select the clinic where you booked your information session: *    

Patient Details

Last Name: (family name) *
First Name: *
Middle Name:
Maiden Name/Former Last Name:
Why do we ask questions regarding sex, sexuality and gender?

Working within the health care sector and providing fertility treatments, we aim to provide a truly inclusive service for all our patients.

To do so there are times we need to ask questions which relate to a patient’s sex, sexuality and gender in order to be able to recommend and provide the most suitable treatment options to assist you.

As a leader in LGBTI+ fertility services, we are committed to providing a high quality and inclusive service to you.
What sex were you assigned at birth? (i.e. what sex was assumed/placed on your original birth certificate) *  
Were you born with a variation of sex characteristics? (this is sometimes called intersex variation)  
Which of the following best describe your current gender identity? *
Do you consider yourself to be:
Pro-nouns:
Date of Birth: *
  /     /  
Residential Address: *  
Town / Suburb: *
   State: *
   Postcode: *
Postal Address: *   ↓ Same as Residential    
Town / Suburb: *
   State: *
   Postcode: *

Home Telephone: *   Work Telephone:
or
Mobile Telephone: *    
Preferred Method of Contact: *  
Email Address: *
Confirm the Email Address: *
Occupation:
Please indicate the suburb and postcode of where your main place of work/employment is located (If applicable):   
Town / Suburb:
   Postcode:
  
At Fertility Specialists of WA we communicate with patients in a variety of ways.

At FSWA we communicate with patients in a variety of ways.

We use the contact information that you provide to assist us to deliver our services.

We aim to be as discrete as possible when we communicate with you in order to protect your privacy.

Please note that the information we send may include sensitive personal details relating to your health/treatment.

By providing us with your details it is implied that you consent to us contacting you via phone, text message, email and or post.

Please let staff know if you wish not to be contacted via a certain medium.

Please refer to our privacy policy for more information.
Are you an Australian or New Zealand Citizen? *  
Are you of Aboriginal or Torres Strait Islander Origin? *
 
 
Country of Birth: * Country of Residence: *
If you were born in Australia which State, were you born in?
Ethnic Background: *
First Language: *
Do you require an interpreter? *  
If Yes, for which language?
Do you have an Australian Medicare card number? *  
Medicare Number: *
First name as on Medicare card: * Last name as on Medicare card: *
Medicare Card Reference Number: *    
Medicare Card Expiry Date: *
  /  
Do you have a Health Care Card? *  
Health Care Card Number: *
Health Care Card Expiry Date: *
  /  
Name of Private Health Fund:
Private Health Membership Number:
Private Health Level of Cover:
Known Allergies: - e.g. pollen, tree nuts, silicates, penicillin, etc. *
Height: cm / centimetres *   Weight: kg / kilograms *   BMI:
Emergency Contact Name: *   Emergency Contact Number: *

Referring GP and Couple Requirements


Referring Family Doctor (GP):
Name: *
Address: *
Fertility Specialist: *
Why do we ask about criminal history?

In some states in Australia it is a legislative requirement to

ask about a patients criminal history.

Do either you or your partner (if applicable) have a criminal history? *  
Do either you or your partner (if applicable) have a disability? *  
If Yes, please let us know about any adjustments you may require:
How did you hear about the clinic? *

Patient's Previous Treatments

Have you previously undergone Intrauterine (IUI) Insemination cycles? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
Have you previously undergone IVF cycles? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
Have you previously frozen embryos? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
If you have had treatment at another IVF clinic please provide the main reason for changing clinics:  

Partner's Details (if applicable)

Do you have a partner? *  
Please complete the following questions relating to your partner.
Last Name: (family name) *
First Name: *
Middle Name:
Maiden Name/Former Last Name:
What sex were you assigned at birth? (i.e. what sex was assumed/placed on your original birth certificate) *  
Were you born with a variation of sex characteristics? (this is sometimes called intersex variation)  
Which of the following best describe your current gender identity? *
Do you consider yourself to be:
Pro-nouns:
Date of Birth: *
  /     /  
Residential Address: *  ↓ Same as Patient
Town / Suburb: *
   State: *
   Postcode: *
Postal Address: *  ↓ Same as Patient    ↓ Same as Residential
Town / Suburb: *
   State: *
   Postcode: *
↓ Same contact & email details as the Patient
Home Telephone: *   Work Telephone:
or
Mobile Telephone: *    
Preferred Method of Contact: *  
Email Address: *
Confirm the Email Address: *
Occupation:
Please indicate the suburb and postcode of where your main place of work/employment is located (If applicable):   
Town / Suburb:
   Postcode:
  
Are you an Australian or New Zealand Citizen? *  
Are you of Aboriginal or Torres Strait Islander Origin? *
 
 
Country of Birth: * Country of Residence: *
Ethnic Background: *
First Language: *
Do you require an interpreter? *  
If Yes, for which language?
Do you have an Australian Medicare card number? *  
Medicare Number: *
First name as on Medicare card: * Last name as on Medicare card: *
Medicare Card Reference Number: *    
Medicare Card Expiry Date: *
  /  
Do you have a Health Care Card? *  
Health Care Card Number: *
Health Care Card Expiry Date: *
  /  
Name of Private Health Fund:
Private Health Membership Number:
Private Health Level of Cover:
Known Allergies: - e.g. pollen, tree nuts, silicates, penicillin, etc. *
Height: cm / centimetres *   Weight: kg / kilograms *   BMI:
Emergency Contact Name: *   Emergency Contact Number: *

If your proposed treatment is to freeze eggs - no partner registration is required.

Partner's Previous Treatments

Have you previously undergone Intrauterine (IUI) Insemination cycles? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
Have you previously undergone IVF cycles? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
Have you previously frozen embryos? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
If you have had treatment at another IVF clinic please provide the main reason for changing clinics:  
Do you consent to our Marketing team contacting you in relation to marketing and media activities? *  

If you no longer wish to receive information from us at any stage, please contact the clinic. Please refer to our privacy policy for more information.

The " * " symbol indicates where form-values are required / mandatory.