Andrology - Electronic Registration

Andrology Registration Form
 
Thank you for booking in for an andrology (sperm test) appointment with Fertility Specialists of Western Australia.

Prior to your andrology appointment you are required to complete the registration form below. This information will help us to prepare in advance for your appointment. If you have a partner, please also complete their details in the registration form below.


About the Testing


Facilities are available at the clinic to produce your semen sample. You may produce your sample at home if you prefer, provided the sample is received at our laboratory within one hour of production (an appointment is still required). It is preferable that you have not ejaculated for at least two full days and not more than five days prior to producing your semen sample.

Please note: that when producing your sample you must not use any lubricants as these may affect the quality of the sample. The sample must also not come into contact with any water.

On the day of your appointment you will need to bring your referral as well as photo ID in the form of either a driver's licence, passport or student ID card for identification purposes. Please note if you have been referred to the clinic for a sperm freeze you are required to have completed pathology screening bloods (HIV, Hep B, Hep C) prior to your appointment, please organise these through your referring Doctor.

Please note that payment for all testing is required on the day of your appointment. Please feel free to contact our friendly patient services team for information regarding the costs associated with andrology testing.


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 have booked your andrology appointment: *    

Patient Details

Surname: (family name) *
First Name: *
Preferred Name:
Gender at Birth: *  
Gender Identify as: *  
Date of Birth: *
  /     /  
Residential Address: *  
Town / Suburb: *
   State: *
   Postcode: *
Postal Address: *   ↓ Same as Residential    
Town / Suburb: *
   State: *
   Postcode: *
Medicare Number: *
Medicare Card Reference Number: *    
Medicare Card Expiry Date: *
  /  

Home Telephone: *   Work Telephone:
or
Mobile Telephone: *    
Email Address: *
Confirm the Email Address: *
Occupation: *
Country of Birth: *
Known Allergies: - e.g. pollen, tree nuts, silicates, penicillin, etc. *
Height: cm / centimetres *   Weight: kg / kilograms *
Emergency Contact Name: *   Emergency Contact Number: *

Partner's Details (if applicable)

Surname: (family name) *
First Name: *
Note: If Not Applicable, please leave partner-name blank.
Preferred Name:
Gender at Birth: *  
Gender Identify as: *  
Date of Birth: *
  /     /  
Residential Address: *  ↓ Same as Patient
Town / Suburb: *
   State: *
   Postcode: *
Postal Address: *  ↓ Same as Patient    ↓ Same as Residential
Town / Suburb: *
   State: *
   Postcode: *
Medicare Number: *
Medicare Card Reference Number: *    
Medicare Card Expiry Date: *
  /  
↓ Same contact & email details as the Patient
Home Telephone: *   Work Telephone:
or
Mobile Telephone: *    
Email Address: *
Confirm the Email Address: *
Occupation: *
Emergency Contact Name: *   Emergency Contact Number: *

Referring GP and Couple Requirements


Referring Family Doctor (GP):
Name: *
Address: *
Fertility Specialist: *
Do you require an interpreter? *  
If Yes, for which language?
Do you have a physical disability? *  
If Yes, do you require wheelchair access?  
Are you visually or hearing impaired? *  
If Yes, what do you require assistance with?  
How did you hear about the clinic? *
The " * " symbol indicates where form-values are required / mandatory.