Download - Yap Specialist

Dr Yen-Yung Yap
MBBS (Adel), FRANZCOG, MRMed
Address: 680 South Road, Glandore SA 5037
Postal: PO Box 225, Edwardstown, SA 5039
ABN 15 817 932 007
Phone 08 82974338 / 0422 014 044
Fax 08 8297 5823
Email [email protected]
Hi,
Thank you for choosing us to provide you specialist care. To assist us in providing you a prompt and effective service,
would you mind filling out the questionnaire form as attached below? Once we receive your fill-out questionnaire
form, we shall contact you to confirm your appointment date and shall endeavour to book you in within 2 weeks'
time. Should you have any difficulties answering some of the questions, feel free to discuss this with us when you
come in for your first appointment. You may return the form by mail, using the reply envelope provided, preferably
within 5 days prior to your preferred date of appointment. You may also return the form via fax or email, if this
method is of convenience to you.
Please try to arrive at least 15min before your appointment time to complete our registration. If you were
running late for your appointment, we would appreciate your courtesy call of such event.
On that day, the things to remember bringing in are:
￭ Your doctor’s referral letter;
￭ The original filled-out Questionnaire form if not already returned by mail;
￭ Copy of all pathology results and imaging films & report if you have them;
￭ Your Medicare card, Health fund card, and photo ID card (e.g. driver’s licence, passport); and
￭ Cash, bankcard or credit card depending on your preferred payment method. Note, for electronic
payment, we accept EFTPOS, Visa and MasterCard only.
For further enquiries, please feel free to email us (at [email protected]) or ring the practice (at 08 8297
4338) during office hours (Mon-Fri, 9am till 5pm).
We look forward to seeing you on the day.
Warm regards,
Ms Mei-Khing Loo
Practice Manager
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Yap Specialist
Dr Yen-Yung Yap
ABN 15 817 932 007
Title: ………………
MBBS (Adel), FRANZCOG, MRMed
Surname: ……………………………………..
Given Name: ……………………….…………………………
Preferred Name: …………………………………..........................
Date of Birth: …….……………………..............
DD / MM / YYYY
Name of Next-of-kin: ………………………………………………….…
Marital status:
☐ married
☐de facto
☐
Relationship: ……………………………………………………..
single
☐ same sex couple
Please tick the most appropriate one
Postal Address: …………………………...........................................................................
Street number & name, Suburb, State
Phone Number:
………………………………………….
(area code) 0000 0000
Email address:
Post code: ……………………
Mobile phone: ………………………………………….
0400 000 000
……………………………………………………………………………………………………..….
Preferred mode of communication:
Mobile phone / Home phone / Office phone / SMS / Email
Please indicate order of preference
and state 'No' to the ones you object
Occupation: ……………………………………………………………………………………………….………………..….
Where did you hear from us:
Please tick the most appropriate
☐ doctor ☐ word of mouth ☐ social media ☐ website
☐ others, please specify:…………………………………………………………….………..
Name of your usual / referring doctor: …………………………………………………………………………………………………..
Address of your doctor's practice: …………………………………………………………………………………………………..
Street number & name, Suburb, State, Postcode
Emergency contact
Name: …………………………………………………………....
Relationship: ……………………………………………………….
Phone/mobile number: ………………………………………….
Medicare No:
Health Fund:
Expiry:
MM / YY
Expiry:
MM / YYYY
……………………………………………………………………………….
Health Fund number:
………………………………………………………………….
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Fertility history:
How long (months/years) have you been trying to conceive? How many times a week do you usually have unprotected intercourse?
Previous fertility assessment and treatment:
List out the investigations and treatments – specify the dates & location, results/outcome, name of gynaecologist(s). Remember to bring in copy of
results and letters
Date of first day of your last menstrual period:
Menstrual cycle:
☐ Regular
DD/ MM / YYYY
☐ Irregular
Please tick one
How many days do your menstrual cycles usually take?
……………………………........
From beginning of one period to the beginning of the next period
Do you have the following symptoms? Please tick your answer, more than one if applicable
☐Heavy period ☐painful period
☐intermenstrual spottings
☐bleeding after sex
Have you used any form of contraception? If yes, please specify the type and period of use.
......................................................................................................................................................................
Gynaecological history:
Conditions; treatments; date (month & year) of diagnosis and treatment
Date of Last PAP smear:
MM / YYYY
Previous abnormal PAP:
Previous HPV vaccination
Yes / No
Yes / No
Results:
…………………………...
If yes, what year? ………………………..….
Date of last sexually transmitted disease screening:
MM / YYYY
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Results:
……………………………..…
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Pregnancy history:
Total number of pregnancies; the number of miscarriages, terminations, ectopic pregnancies, deliveries (specify whether you have natural birth,
instrumental delivery or caesarean section; any labour complications); the dates (month & year); and location
Medical & surgical history:
Conditions; treatments; date (month & year) of diagnosis and treatment; surgical/anaesthetic complications
Medications:
Type, dosage, frequency and route; including alternative/herbal medicines & supplements
Drug allergies:
……………………………………..………………………………………………………………………………………………………..
Do you smoke, drink alcohol, or take recreational drugs? Have you been expose to hazardous materials?
If yes to any of the above, please specify type, amount and period of exposure
Family history:
Including genetic diseases, cystic fibrosis, cancers and blood/bleeding disorders
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In the last 12 months: Tick the boxes describing the things you have done. Remember to bring in copy of the results/letters
☐
☐
☐
☐
Any blood tests
Any radiology tests including ultrasound scan, hysterosalpingogram
Semen analysis
Seen other specialists
Other information you may wish to provide OR issues you may wish to address OR your expectations:
Tick one or more boxes describing your expectations
Your expectations
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Recommended session time
A comprehensive and detailed assessment covering all relevant women’s health
issues, fertility and long term health
First consult: 45-60 min
Review consult: 30-60 min
A detailed explanation of my condition(s)
Discussion on the various management options / choices available
A holistic and individually-tailored management plan
A focused assessment & management based on a complex area of concern
First consult: 30-45 min
Review consult: 30 min
A focused assessment based on a minor area of concern
A second opinion
First consult: 30 min
Each consult: 15-30min
A basic / simplified explanation
Doctor to decide my management on my behalf following standard practice
A budget conscious management plan, i.e. one which incurs the least gap
Onsite ultrasound scan on the day of consult.
Additional 30 min
[Note: Medicare rebate for ultrasound scan will be reduced by $ 35 if combined with consult]
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I acknowledge, confirm and agree to all of the following terms of engagement:
1.
2.
3.
4.
All the above information provided is true and accurate to the best of my knowledge.
I give consent for the practice to obtain my medical record from doctors/institutions which I have received medical care.
I understand that the practice will protect my confidential information to their best endeavour but cannot guarantee such
protection caused by others with criminal intent. Under the Privacy Act 1988 (Cth), you have the right to request a copy of your
medical record but you will need to request in writing or fill in our form 'Release of information'. Fees may apply, and must be
paid prior to the release, to cover the time and effort required of us to comply with the Privacy Amendment (Enhancing Privacy
Protection) Act 2012.
I understand and agree to pay consultation fee in full on the day of consultation; and to pay in full all fees for procedures and
ultrasound scan on the day of service. I also agree to pay these services in full as a deposit at the time of booking if requested by
the practice and understand the booking is not confirmed unless payment is rendered. I can book the session for a specific
duration and will pay the session based on the fee schedule described below. The consult fee is not deductable / refundable on
the day of consult. Claiming of rebates from Medicare and/or Health fund shall be my sole responsibility although the practice
can, in good faith, assist me in this regard.
Consult fee:
No gap for the initial consult for a patient in the first 15min. Additional fee applies for subsequent
consult time at a flat rate of $70 at every 15min interval.
Procedures:
fees as prescribed by Yap Specialist in reference to the Australian Medical Association fee schedule,
unless otherwise agreed by Yap Specialist in writing to follow your health fund gap cover scheme
Pelvic/transvaginal scan: $ 180 - $210, payable on the day of scan
Cancellation fee:
equivalent to full consult fee, payable if I failed to attend my appointment and did not notify the
practice at least 10 working days prior to the appointment date. If the practice is notified 11-20
days prior to the appointment date, the cancellation fee payable would amount to 50% of the full
consult fee
Fee schedule is subject to change from time to time, and you will be notified in due course. Medicare rebate applies if you are eligible, have a referral
letter, and have attended the consult. Medicare rebate is claimable per attendance. Please contact Medicare for more information. Out-of-pocket
expense (or gap) is the difference between your consult/procedure fee(s) and your Medicare rebates, and start from $ 17.25.
5.
I understand that failure to pay the full fee could result in legal action and/or debt collection which may incur additional charges
payable fully by myself.
6. I understand that there may be additional fees/charges from ancillary services like pathology tests, imaging tests, surgical
assisting, anaesthetics, allied-health services etc. These services will only be performed after consultation with Dr Yap. I will be
given opportunity to enquire about these services and associated fees, and can accept/decline these services at my own
discretion. Claiming of rebates from Medicare and/or Health fund shall be my sole responsibility although the practice can, in
good faith, assist me in this process.
7. Independent advice is available to me from other medical professionals, and that it is in my interest to obtain such advice before
giving my consent and signing any agreement with Yap Specialist.
8. If English is not my first language, it is my responsibility to arrange for an interpreter service at my own expense. It is my choice
to engage my relatives or anyone as my interpreter, and I am aware of and accept the limitation this may pose, and will not hold
Yap Specialist liable for any mishaps as a result of any miscommunication, if I choose/insist not to engage a qualified independent
interpreter.
9. I can always ask for a chaperone, e.g. my partner/parent/friend/female staff, prior to any examination. Nonetheless, I can decline
having a chaperone for my own privacy and will not hold the examining doctor liable for the absence of chaperone in this instance.
The doctor can, at his/her discretion, decline or defer examination in the absence of a chaperone. I give consent for the
attendance of a female staff should the doctor require an assistant.
10. As Yap Specialist is actively involved in research, training and education for the public community, medical students, GPs and
other health professionals, Dr Yap may from time to time collect and present/publish case studies and clinical photographs to
the audience/readers. Real names and identifiable personal information will be deleted to maintain confidentiality. Dr Yap will
obtain your prior verbal consent should the information/photo of your condition be used for this purpose. If you object to this,
please cross out this clause altogether and state ‘DECLINE’ over the clause.
Signed:
Date:
DD / MM / YYYY
………………………………………………………………………..
Name:
………………………………………………………………………..
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