Womens Health Clinic Self-Referral Form

Reason for attending:*

• Contraception Advice (Mirena/IUD)
• Mirena/IUD Removal ONLY
• Contraception Advice (Implanon)
• Unplanned Pregnancy*
• Pre-conception Counselling
• Perimenopause/Menopause
• Antenatal Care
• Postnatal Care
• How many weeks?:
  
• Pelvic Pain/Heavy/Abnormal Uterine Bleeding
• Infertility
• Vaginal Prolapse

Comments:

Before submitting this request, by ticking the boxes below I acknowledge that:

• This clinic is a private clinic and charges private fees
• Fees for late cancellation and non-attendance of 75% of the full cost of the consultation will apply
• Any previously outstanding accounts will need to be addressed prior to attending your initial consultation with Women's Health @ Hawkins
• I am attending the Women’s Health @ Hawkins for the above reason ONLY and accept that I may be referred to my usual GP for any condition outside the scope of the Women’s Health clinic.

Requests for appointments where these boxes are not ticked may not be offered an appointment.

If you have not received a phone call from Hawkins Medical Clinic within 7 days of submitting your referral please contact the clinic on 8725 5266.