Patient Registration

Do you suffer from vaginal dryness, itching, burning or pain with intercourse?

Time period since symptoms commenced

Do you experience an urgent desire to pass urine?

Time period since symptoms commenced?

Do you frequently need to go to the toilet to pass urine?

Time period since symptoms commenced?

Any previous gynaecology surgical procedure or medical treatment?

Was this for cancer?
No Yes

Are you up to date with your cervical smear screening program?

Are you currently pregnant or trying to conceive?
No Yes

First name

Last name

How old are you?

Email address

Confirm email address

Mobile no.

Postcode

Recommended by a clinician - please insert name

How would you like to be contacted regarding your consultation?

Phone

Post

First line of your address

Town

Data consent

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I consent to having my data recorded.