(08) 6289 3838
admin@oasisfertilitycentre.com.au
About
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Fertility Services
Free Fertility Assessment
Donor Program
Donor Program
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Recipients
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Service Enquiry
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Cost
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Common Questions
Wellness Centre
Stress & Fertility
Counselling & Psychology
Acupuncture
Naturopathy
Diet & Nutrition
Sound Healing
Contact Us
Make A Booking
MAKE A BOOKING
About
Our Vision
Our Team
Services
Fertility Services
Free Fertility Assessment
Donor Program
Donor Program
Egg Donors
Embryo Donors
Sperm Donors
Recipients
Laboratory Services
Service Enquiry
Our Success Rate
Cost
Resources
Patient Resources
GP Resources
Common Questions
Wellness Centre
Stress & Fertility
Counselling & Psychology
Acupuncture
Naturopathy
Diet & Nutrition
Sound Healing
Contact Us
Step
1
of
3
33%
Referral to
Fertility Specialist
Fertility GP
Reason for Referral
(Required)
Fertility Evaluation
Egg Freezing
Other
Referral For:
Patients Full Name
(Required)
Patients Date of Birth
(Required)
MM slash DD slash YYYY
Patients Phone
(Required)
Patients Email
(Required)
Medicare Ref Number
(Required)
Medicare Expiry
(Required)
Do you have Private Health Insurance?
(Required)
Yes
No
Fund Name
(Required)
Member Number
(Required)
If Applicable (All fertility consultations with specialists require both partners present)
Partners Full Name
(Required)
Partners Date of Birth
(Required)
MM slash DD slash YYYY
Partners Phone
(Required)
Partners Email
(Required)
Medicare Ref Number
(Required)
Medicare Expiry
(Required)
Do they have Private Health Insurance?
(Required)
Yes
No
Fund Name
(Required)
Member Number
(Required)
Referring Doctor:
Doctors Name
(Required)
Practice Name
(Required)
Practice Email
(Required)
Practice Phone
(Required)
Practice Fax
(Required)
Health Questionnaire for Patient
Are you currently trying to conceive?
(Required)
Yes
No
How long have you been trying to conceive?
(Required)
Have you been pregnant before?
(Required)
Yes
No
How many times?
(Required)
How many live births?
(Required)
Do you have any known fertility issues?
(Required)
Yes
No
Please provide details
(Required)
Have you ever had any previous gynaecological surgeries?
(Required)
Yes
No
Please provide details
(Required)
Medical History
Have you been diagnosed with ay chronic medical conditions? (e.g. diabetes, hypertension, thyroid disease)
(Required)
Yes
No
Please provide details:
(Required)
Are you currently taking any medications?
(Required)
Yes
No
Please list them
(Required)
Are you currently taking any supplements?
(Required)
Yes
No
Please list them
(Required)
Please list your current:
Height (cm)
(Required)
Weight (kg)
(Required)
BMI
(Required)
Lifestyle History
Are you a current smoker?
(Required)
Yes
No
Do you consume alcohol on a regular basis?
(Required)
Yes
No
What is your current occupation?
(Required)
Are you a FIFO worker
(Required)
Yes
No
Family History
Do you have a family history of fertility issues?
(Required)
Yes
No
Please provide details
(Required)
Do you have a family history of genetic disorders or birth defects?
(Required)
Yes
No
Please provide details
(Required)
Do you have a family history of chronic medical conditions?
(Required)
Yes
No
Please provide details
(Required)
Additional Information
(Required)
Please feel free to provide any other relevant information or concerns regarding your fertility and overall health:
Will your partner be attending the appointment with you? (Please note: Partners will need to attend for all fertility consults and treatments other than elective egg freezing)
(Required)
Yes
No
Health Questionnaire for Partner
Have you fathered a child in the past?
(Required)
Yes
No
How many children do you have?
(Required)
How long have you been trying to conceive with your current partner?
(Required)
Do you have any known fertility issues?
(Required)
Yes
No
Please provide details
(Required)
Medical History
Do you experience any difficulties in achieving or maintaining an erection?
(Required)
Yes
No
Have you noticed any recent changes in your libido or sexual desire?
(Required)
Yes
No
Have you previously undergone any testicular surgery?
(Required)
Yes
No
Please provide details
(Required)
Have you been diagnosed with ay chronic medical conditions? (e.g. diabetes)
(Required)
Yes
No
Please provide details
(Required)
Are you currently taking any medications?
(Required)
Yes
No
Please list them
(Required)
Are you currently taking any supplements?
(Required)
Yes
No
Please list them
(Required)
Height (cm)
(Required)
Weight (kg)
(Required)
BMI
(Required)
Lifestyle History
Are you a current smoker?
(Required)
Yes
No
Do you consume alcohol on a regular basis?
(Required)
Yes
No
What is your current occupation?
(Required)
Are you a FIFO worker
(Required)
Yes
No
Family History
Do you have a family history of fertility issues?
(Required)
Yes
No
Please provide details
(Required)
Do you have a family history of genetic disorders or birth defects?
(Required)
Yes
No
Please provide details
(Required)
Do you have a family history of chronic medical conditions?
(Required)
Yes
No
Please provide details
(Required)
Please upload:
Please note... The following uploads are all mandatory for a direct appointment with our fertility specialists. If any of the following investigations are outstanding, please
return to the start of the form
and select the "Fertility GP" function or contact our friendly reception team for assistance.
Referral From GP
(Required)
Max. file size: 2 MB.
Anti-Mullerian Hormone (AMH)
(Required)
Max. file size: 2 MB.
Androgen studies (Androsternidione, DHEA, SHBG, testosterone and FAI)
(Required)
Max. file size: 2 MB.
Blood group & Antibodies
(Required)
Max. file size: 2 MB.
Cervical screening test
(Required)
Max. file size: 2 MB.
Ca125
(Required)
Max. file size: 2 MB.
Full blood count
(Required)
Max. file size: 2 MB.
Fasting glucose/Insulin studies
(Required)
Max. file size: 2 MB.
Hepatitis B/C serology
(Required)
Max. file size: 2 MB.
HIV serology
(Required)
Max. file size: 2 MB.
Hormone profile (LH,FSH, E2, Prl)
(Required)
Max. file size: 2 MB.
Pelvic ultrasound
(Required)
Max. file size: 2 MB.
Rubella serology
(Required)
Max. file size: 2 MB.
Syphilis serology
(Required)
Max. file size: 2 MB.
Thyroid Function Test
(Required)
Max. file size: 2 MB.
Urine (Ureaplasma/Mycoplasma PCR)
(Required)
Max. file size: 2 MB.
Urine (Chlamydia/Gonorrhoea PCR)
(Required)
Max. file size: 2 MB.
Varicella serology
(Required)
Max. file size: 2 MB.
Investigations for Partner:
Hepatitis B/C serology
(Required)
Max. file size: 2 MB.
HIV serology
(Required)
Max. file size: 2 MB.
Semen analysis
(Required)
Max. file size: 2 MB.
Syphilis serology
(Required)
Max. file size: 2 MB.
Urine (Chlamydia/Gonorrhoea PCR)
(Required)
Max. file size: 2 MB.
Urine (Ureaplasma/Mycoplasma PCR)
(Required)
Max. file size: 2 MB.
At Oasis Fertility, we understand there is always more to a story. Please feel free to tell us in your own words how Oasis Fertility can help you.
At Oasis Fertility, we understand there is always more to a story. Please feel free to tell us in your own words how Oasis Fertility can help you.
(Required)
If English is not your first language, do you require an interpreting service
Yes
No
What language do you require interpreting services for?
Reason for Referral
Fertility Evaluation
Egg Freezing
Other
Referral For:
Patients Full Name
(Required)
Patients Date of Birth
(Required)
MM slash DD slash YYYY
Patients Phone
(Required)
Patients Email
(Required)
Medicare Ref Number
Medicare Expiry
Do you have Private Health Insurance
Yes
No
Fund Name
Member Number
If applicable:
Partners Full Name
Partners Date of Birth
MM slash DD slash YYYY
Partners Phone
Partners Email
Medicare Ref Number
Medicare Expiry
Do they have Private Health Insurance
Yes
No
Fund Name
Member Number
Regular Doctor Details (If you have one)
Doctors Name
Practice Name
Practice Phone
Practice Fax
Please Upload any relevant investigations or imaging performed in the last year (hormone profile, pelvic ultrasound, viral serology, sexual health screening)
Drop files here or
Select files
Max. file size: 2 MB, Max. files: 20.
At Oasis Fertility, we understand there is always more to a story. Please feel free to tell us in your own words how Oasis Fertility can help you.
At Oasis Fertility, we understand there is always more to a story. Please feel free to tell us in your own words how Oasis Fertility can help you.
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