STI Health Check Patient Registration
First Name
*
Surname
*
Date of birth
*
/
Day
/
Month
Year
Date
Email
*
example@example.com
Mobile Phone Number
*
Address
*
Medicare Card Number
Medicare Card Line Number (Which number are you on the card)
Request Date
/
Day
/
Month
Year
Date
Would you like your results sent to your GP?
*
No
Yes
Your GP's Name
Your GP's Clinic Name
Why are you wanting to do an STI check?
*
As part of a general health check. I have no symptoms
I have some symptoms I am concerned about
I have previously been diagnosed with an STI
My partner has some symptoms of an STI
My partner has been diagnosed with an STI
What symptoms do you have?
Unusual Discharge from Penis or Vagina
Pain or Burning During Urination
Genital or Anal Itching or Irritation
Genital Sores, Blisters, or Ulcers
Pain During Sex
Lower Abdominal or Pelvic Pain
Unusual Genital or Anal Rash
Swollen or Painful Lymph Nodes (e.g., Groin)
Fever or Flu-Like Symptoms
Other
What STI have you previously been diagnosed with?
HIV
Hepatitis B
Hepatitis C
Syphilis
Gonorrhoea
Chlamydia
Genital Herpes
Other
What symptoms does your partner have?
Unusual Discharge from Penis or Vagina
Pain or Burning During Urination
Genital or Anal Itching or Irritation
Genital Sores, Blisters, or Ulcers
Pain During Sex
Lower Abdominal or Pelvic Pain
Unusual Genital or Anal Rash
Swollen or Painful Lymph Nodes (e.g., Groin)
Fever or Flu-Like Symptoms
Other
What STI has your partner been diagnosed with?
HIV
Hepatitis B
Hepatitis C
Syphilis
Gonorrhoea
Chlamydia
Genital Herpes
Other
How would you describe your sexual orientation?
Straight
Gay
Bisexual
Prefer not to say
Other
Do you have any medical conditions?
*
No
Yes
What medical conditions do you have?
Do you take any medications?
*
No
Yes
What medications do you take?
Do you have any drug allergies?
*
No
Yes
What drugs are you allergic to?
Have you seen a doctor from Vasectomy Australia in person for a procedure or consultation in the last 12 months?*
No
Yes
My Products
*
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STI HealthCheck
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95.00
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Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please verify that you are human
*
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