Online Booking Form

Surname *
First Name *
Date of Birth
Contact Number *
Please make sure you enter a valid phone number as your appointment cannot be confirmed until we speak with you.
Preferred time for us to call you
Can we email you? yes no
If yes, please supply your email address
Do you have a current medicare card? yes no
Do you have a current Centrelink Healthcare or Pension Card? yes no
Which Centre would you prefer?
Please note we do not provide termination of pregnancy services in all centres every day. When we telephone you we will endeavour to make the most convenient appointment time and date for you.
When was the first day of your last period?
If you have had an ultrasound, when was it?
How many weeks pregnant were you on the ultrasound?
Are you currently taking any medication? yes no
If yes, If yes please list your medicines
If you have any specific questions please list them below
I consent to Gynaecology Centres Australia telephoning me to arrange an appointment. I understand that I have not made a firm appointment until I have spoken to a representative of Gynaecology Centres Australia.
I understand and agree with the above statement