New Patient Information Sheet
New patients of the Endo Urology Centre are requested to fill out a Patient Information Sheet.
If you are a new patient and have an appointment with Dr Nagaonkar, to save time in the waiting room you can fill out this form in advance.
You may choose either of the following options:
- Download the Patient Information Sheet in PDF format, print it and bring the completed sheet with you to your appointment. Click here to download. Or…
- Fill out the online version of the sheet below, and submit it over the internet.
Note: If you are a male patient and have one of the following symptoms, please also request a Urinary Symptom Assessment Form from the reception desk on arrival:
- Urinary frequency
- Urgency
- Reduced urine stream, etc.
Send New Patient Information online
Note that you should only submit this form if you have an appointment to see Dr Nagaonkar.
Please complete as many sections as you are able to. Fields marked “required” must be filled in before you can submit the form.
An important note about privacy
To comply with the Privacy Act 2001, all patients need to provide consent for the following important aspects of their medical care:
- I agree that Dr Nagaonkar takes a full medical history that relates to my medical condition and management.
- I agree that relevant information may be obtained from other medical practitioners, such as GPs and Specialists, other health care providers, pathologists, hospital and day surgery units as necessary.
- I agree that Dr Nagaonkar may discuss my medical history diagnosis and management with my general practitioner and other relevant medical specialists in relation to medical management.
- I understand that I may apply to access my health records.
- I agree that Dr Nagaonkar keeps a database and that this information may be used in an anonymous fashion for research purposes.
- I agree that Dr Nagaonkar collects relevant information (e.g. X-rays) in digital format to monitor my progress and/or for research purposes.
By submitting the form below, you are deemed to have consented to the above conditions.
