Dr Sylvia Ross 

and

Dr Rebecca Mackenzie-Proctor

Registration Form 

CLIENTS INFORMATION (SPERM PROVIDER)

Client Details

Title

First Name (as per Medicare)

Last Name (as per Medicare)

Date of Birth

Preferred Name

Biological Sex

Pronouns

Relationship Status

SingleDe FactoMarried Same Sex PartnerOther

Occupation

Height

Weight

Do you require translation services?

YesNo

Ethnicity

ATSI

AboriginalTorres Strait Islander

Main Concern for Consultation

Contact Details

Mobile Phone

Email

Address (as per Medicare)

Street addressStreet address line 2

City

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Medicare/Insurance Details

Medicare Number

Position

Expiry

Private Health Provider

Policy Number

Emergency Contact

Full Name

Next of kin - Relationship

PartnerMotherFatherSiblingFriendOther

Mobile

Referral Details

Usual GP’s Name

Clinic Name

How Did You Hear About Us

Interested Parties (list any additional clinicians who should receive the results)

Please Upload Referral and Results

Browse

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Reproductive History

Have You Fathered Children Before

YesNo

How Many

Have you had fertility treatment previously

YesNo

Details And Outcome

Previous Semen Analysis

YesNo

Pathology Company/Date

Testicular/Gential History

Undescended TesticlesTesticular TorsionHernia SurgeryVaricoceleTesticular Infections Such As Epididymitis, Orchitis Or Mumps Involving TesticlesExposure To Heat (E.G. Saunas, Laptops On Lap, Cycling For Long Periods)

Other

Medical History

Ongoing Medical Conditions

YesNo

Details

Previous Surgeries (Incl. Reproductive)

Yes No

Year Of Surgery

Any Complications

Medications And Supplements

Current Medications

Vitamins/Supplements

Allergies (Medications, Latex, Etc.)

Environmental Exposure

Exposure To Chemicals/Radiation/Heavy Lifting/High Stress

YesNo

Details

Family History

Inherited/Genetic Disorders In Family

YesNo

Details

Fertility Issues In Relatives

YesNo

Lifestyle Factors

Do You Smoke

YesNoEx Smoker

How Much

Alcohol Consumption

YesNo

How Often

Recreational Drugs

YesNo

Type

Frequency

Have You Used Performance Enhancers Or Testosterone

YesNo

How Often

Any Food Restrictions

YesNo

Details

Do You Drink Caffeinated Drinks

YesNo

If Yes, How Often

What Type

CoffeeTea (Including Green Tea)Energy Drinks Chocolate

Do You Exercise

YesNo

If Yes, What Type And How Often

Sexually Transmitted Infections (STI) And Sexual Health

Have You Been Sexually Active

YesNoPrefer not to say

History Of STIs

YesNo

Which

Treated

YesNo

Consent

I am aware that artificial intelligence (AI) may be used for note-taking during consultations.

I understand that my personal and health information will be kept confidential and used solely for the purposes of my care and treatment in compliance with VIC Health and Privacy legislation.

I consent to my information being shared with treating doctors, nurses, embryologists, and other relevant healthcare providers involved in my care.

I understand my records are kept confidential and securely stored in compliance with VIC Health and Privacy legislation.

I understand it is my responsibility to notify of any change to or correction of my personal information, inlcuding relationship status.

I understand I may request access to my health information by contacting the clinic in writing.

I consent to being contacted by the clinic via phone, email, or SMS regarding appointments, results, and treatment updates.

I consent to the use of my de-identified data for clinical audit or quality improvement purposes.

I acknowledge that I am responsible for payment of any applicable consultation and treatment fees.

If applicable, I consent to relevant medical information being shared between myself and my partner for the purpose of joint fertility treatment.

I understand that I may withdraw or modify my consent at any time by notifying the clinic in writing.

I confirm that the information I have provided is accurate and complete to the best of my knowledge. *

Patient/ Guardian Signature

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