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Appointment Details

Appointment type*New Patient - Gold Coast Rooms4D Pelvic Floor Ultrasound

Personal Details

Date of birth*

Postal Address*

Do you have a Medicare Card?*YesNo

Do you have private hospital cover (private health)?*YesNo

Do you have a DVA card?*YesNo

Medical Concerns

Do you experience: *You may select more than one symptom
Prolapse - feels like something is coming down or a lump in your vaginaUrinary incontinence - leakage of urine with exercise/activity or when feeling urgentUrinary tract infections - repetitive and requiring antibiotic treatmentsDifficulty passing urinePelvic pain - ongoing pelvic discomfortDifficulty with bowel function - unable to control or difficulty to empty bowelOngoing issues following previous vaginal surgery - including meshOther (Specify in comments area at end of form)

Previous gynaecological surgeries and appointments

Have you had any gynaecological surgery before?*YesNo

If yes, please list:

Referring doctor details

Referring doctor:*

Upload Referral (jpg or PDF accepted):

Appointment policy

Please note that once you have booked an appointment with us it means that we have reserved time in our schedule exclusively for you.
You will receive an appointment confirmation SMS 5 days prior to your appointment. Please reply ‘Y’ to confirm your appointment. Should you need to reschedule or cancel your appointment, please call us at 1300848966 during business hours or email info@vivwong.com.au.

If you cancel or request to reschedule your appointment with less than 2 business days’ notice, or if you “no-show”, a cancellation fee will apply.

Please note that we do not accept cancellation via SMS

Please type your name below to acknowledge that you have read and agree to
the above appointment policy*

Additional comments:

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