Patient Triage Form

The patient triage form gives our specialist team all the relevant information they need to quickly assess your current situation. After we review it a member of our Team will be in touch to confirm your details and give you a consultation date. They will also suggest some relevant tests that may be required before consultation. 

Please ensure to let us know if you have a VHI package with the Relevant Benefits.

Patient Triage Form

  • Female Demographics

  • Date Format: DD slash MM slash YYYY
    New treatments, offers etc.
  • Demographics of the Individual you are seeking treatment with.

    If Applicable
  • Date Format: DD slash MM slash YYYY
    New treatments, offers etc.
  • If applicable
  • Female Medical Information

  • Latex, peanuts?
  • Operations/Childhood Problems/Medical Conditions
  • If yes, how many units?
  • If so where?
  • Painful periods etc?
  • A 4 day variation up or down to your average length in cycle is considered regular.
  • Was it normal?
  • If yes, please give brief details (year, weeks on delivery, results, C-section, complications)
  • If yes, please give brief details (ie. 1 IVF, 1 IUI, tests only etc.)
  • Partner Medical Information

    If applicable
  • Latex, peanuts?
  • Latex, peanuts?
  • Operations/Childhood Problems/Medical Conditions
  • If yes how many units per week?
  • If so where?
  • If yes, please give brief details.
  • If yes, please give brief details (Semen Analysis?)
  • Sharing Data