WEBSITE PATIENT SELF REFERRAL FORM

Welcome to QLD Pelvic Floor Centre

Welcome to QLD Pelvic Floor Centre!

If you are changing your daily activities to accommodate bladder and bowel symptoms, we are here to help you get the relief you need!

Please complete the following questionnaire to the best of your ability.

If you have any issues, please call our friendly admin team on 31937711 and they can help you book the right appointment for your needs.

Take the first step toward better pelvic health with QPFC.....

How Can QPFC Help You?

Many people live with pelvic floor issues, assuming they just have to put up with it - but you don't have to.

If you are experiencing any of the following symptoms, we are here to help you get your quality of life back:

Bowel Concerns: Constipation, diarrhoea, bloating, rushing to the toilet, or accidental leakage.
Bladder Concerns: Leakage, urgency, or feelings of prolapse.
Pelvic Pain: General pelvic discomfort or pain during intercourse.

Expert Care with No Out-of-Pocket Costs

Patients experiencing these symptoms are eligible for a 100% bulk-billed comprehensive initial assessment with our expert Nurse Practitioner. Our Nurse Practitioner specialises in pelvic floor dysfunction and has helped countless patients find relief from life-limiting symptoms.

Remove the Guesswork

If needed, we can perform quick and comfortable bladder and bowel testing to understand exactly what’s causing your symptoms - with absolutely no out-of-pocket cost to you.

Seamless Next Steps

Should your assessment indicate that a referral to another specialist is necessary, our Nurse Practitioner can facilitate a referral for your transfer of care, entirely free of charge.

Ready To Book Your Appointment?

You do not need a referral to book your initial consultation. Simply complete the following form, press submit, and our friendly reception team will reach out to schedule a time that works best for you.

If you have any questions or concerns at all, please do not hesitate to email me at reception@qldpfc.com.au.

We look forward to welcoming you to QPFC very soon!

Warm regards,

Alicia

Practice Manager

Referral Upload

Do you have a referral? *

No, I would like to book an appointment for bulk-billed testing with your Nurse Practitioner and understand I do not need a referral.No, I am not sure who I should see and would like to consult your Nurse Practitioner for guidance and a referral to the most suitable practitioner if necessary.I am a bit unsure - can someone call me, please?Yes, I have a referral to a specialist (please upload below)

File upload

Browse

Please upload a copy of your referral, medication list, previous correspondence, investigations results / reports that you would like to Qld Pelvic Floor Centre to review.

Do you have any of the following symptoms: constipation, diarrhoaea, bloating, rushing to the toilet, accidental leakage (bladder or bowel), urgency, feelings of prolapse, general pelvic pain or discomfort, pain during intercourse? *

YesNo

Patient Information

Given Name *

Middle Name

Surname *

Date of Birth *

Gender *

MaleFemaleOther

Residential Address *

Postal Address

Phone - Mobile *

Phone - Home

Phone - Business

Email

Practice Communication

Medicare

Patient Medicare Number *

Patient Medicare Reference Number (number beside your name) *

Medicare Expiry Number *

Is the PATIENT the person claiming the Medicare rebate? If the patient is a child under 16 years of age and their parent is responsible for the account please select NO. *

YesNo

ACCOUNT HOLDER: FULL NAME - If the patient is under 16 years of age, the primary cardholder is the recognised account holder / recipient of the Medicare rebate. The person with individual refence number 1 on the Medicare card must complete the following information in order to claim the Medicare rebate.

Account Holder - Medicare Number

Account Holder - Reference Number:

Account Holder - Date of Birth

Relationship to Patient

Account Holder - Phone

Private Health Fund

Are you a member of a Private Health Fund? *

YesNo

Name of Health Fund *

Membership Number *

Membership Reference Number:

BUPA ADF

Are your medical fees covered by BUPA ADF as a current serving member? *

YesNo

ADF Referring Practitioner

ADF Referring Practitioner Location

Defence Approval Number (DAN)

EID

DVA

Do You Have a DVA (Department of Veteren's Affairs) Card? *

YesNo

DVA Card Number

WHITEGOLD

DVA PHYSIOTHERAPY: Please note: If you are covered by DVA and seeing a physiotherapist, funding approval must be received prior to your appointment. Please call 3193 7711 or email: reception@qldpfc.com.au in advance to ensure approval can be obtained. Patients will be required to cover the out-of-pocket for non-approved appointments. *

Next of Kin

Emergency Contact - Full Name *

Relationship to Patient

Next of Kin Phone - Home

Next of Kin Phone - Mobile *

General Practitioner

General Practitioner's Name *

Practice Location

Please list other practitioners involved in your care that you would like copied into correspondence from QLD Pelvic Floor Centre

Medical / Surgical History

Current Medications (please list)

Allergies (please list)

Height

Weight

Do you smoke or vape? *

YesNo

If so, please detail your daily intake

Are you diabetic? *

NoYes - Type 1Yes - Type 2

Are you taking any of these medications for overactive bladder? *

Not Applicable Solifenacin Betmiga Oxybutynin

Surgical History (please list)

Practice Fees

ALL NURSE PRACTITIONER INITIAL CONSULTATIONS AND ASSESSMENT ARE BULK BILLED WITH A VALID MEDICARE CARD.

BLADDER (Urodynamic Studies) AND BOWEL TESTING (Anorectal Physiology Studies) ARE BULK BILLED WITH A VALID MEDICARE CARD.

We are pleased to offer online Medicare claiming.

Private consultation fees are detailed below. All consultation fees are payable immediately following your appointment. A flat surcharge of 1% applies to all card transactions (this is the rate charged by the terminal provider). You are welcome to pay by cash to avoid the surcharge however we ask that you bring the correct amount as we do not keep change on the premises.

Cancellations / rescheduled appointments within 48 hours will incur the full appointment fee.

Please give at least 48 hours notice of changes to your appointment so we can offer this time to a patient on our waitlist.

DR ANDREA WARWICK - COLORECTAL SURGEON
	Item	Description	Fee	Medicare Rebate
	104	New Patient	$350	$86.15
	104	New Patient - Complex	$450	$86.15
	105	Review	$250	$42.30
* in addition to consult fee		Haemorrhoid Banding	$150*	$66.95
DR CHRIS GILLESPIE - COLORECTAL SURGEON
	ITEM	DESCRIPTION	FEE	MEDICARE REBATE
	104	New Patient	$350	$86.15
	105	Review	$250	$42.30
	32072	Sigmoidoscopic Examination	$80	$42.30
DR ALEXANDRA MOWAT - UROGYNAECOLOGIST
	Item	Description	Fee	Medicare Rebate
	104	New Patient	$350	$86.15
	105	Review	$250	$42.30
		Initial Pessary + Pessary Fitting	$400*	N/A
* in addition to consult fee		Replacement Pessary	$100*	N/A
DR DUNCAN SHANNON - GYNAECOLOGIST
	Item	Description	Fee	Medicare Rebate
	104	New Patient	$350	$86.15
	105	Review	$250	$42.30
		Initial Pessary + Pessary Fitting	$400*	N/A
* in addition to consult fee		Replacement Pessary	$100*	N/A
DR RACHAEL NUGENT - GYNAECOLOGIST - NAMBOUR
	Item	Description	Fee	Medicare Rebate
	104	New Patient	$350	$86.15
	125	New Patient - Complex / Long Consult	$450	$151.90
	126	Review Patient - Complex Consult	$380	$76.00
	105	Review Patient	$250	$42.30
	126	Somatic Review	$380	$42.30 - $86.15
		Procedure
		Colposcopic Management	$285*	$95.13
		IUD Insertion	$300*	$269.75
		Pessary Fitting	$200*	$86.15
		Replacement Pessary	$100*	$42.30

DR TRINA KELLAR - NEUROGASTROENTEROLOGIST
	Item	Description	Fee	Medicare Rebate
		New Patient (60 - 75 mins)	$600 - $750	$265.60
		Review (15 - 45 mins)	$150 - $450	$76 - $133
		Post Scope Review (30 - 45 mins)	$300 - $450	$133 - $265.60
		Second Opinion (New Patient)	$750 - $1000	$265.60
		Procedure Deposit / Gap	$100	N/A
		Case Conference	variable
DR ANDREW RIDDELL - COLORECTAL SURGEON
	Item	Description	Fee	Medicare Rebate
	104	New Patient	$350	$86.15
	105	Review	$250	$42.30
		Scope Deposit / Gap	$100	N/A
* in addition to consult fee		Haemoband	$55*	N/A
DR PAMELA CALEO - GENERAL SURGEON - NAMBOUR
	Item	Description	Fee	Medicare Rebate
	104	New Patient	$200	$86.15
	105	Review	$100	$42.30
DINA FETAHAGIC - NURSE PRACTITIONER
All Nurse Practitioner consultations are bulk billed with a valid Medicare card. Transanal irrigation education and consultations for patients without a valid Medicare card are charged as below:
	82205	NP Consult >20 minutes	$50	$27.05
	82210	NP Consult - 20 minutes	$100	$51.25
	82215	NP Consult - 40 minutes	$200	$75.60
	91189	NP Tele Consult >20 minutes	$50	$27.05
	91190	NP Tele Consult >20 minutes	$100	$51.25
	91191	NP Tele Consult >20 minutes	$200	$75.60
	82215	Aquaflush Kit + NP Education	$500	$75.60
PELVIC FLOOR PHYSIOTHERAPY
Kate Hooper Leanne Slater Nadina Kurtshenko Jess Forbes Karyn Devlin Liz Johnson	500	New Patient (60 minutes)	$280	N/A
	505	Review (45 minutes)	$195	N/A
	10960	Physio Care Plan from GP - New	$280	$61.80
	10960	Physio Care Plan from GP - Review	$195	$61.80
* in addition to consult fee		Initial Pessary + Pessary Fitting	$200*	N/A
* in addition to consult fee		Pessary Replacement	$100*	N/A

Allison Bryant	500	New Patient (90 minutes)	$300	N/A
	505	Review (45 minutes)	$195	N/A
	10960	Physio Care Plan from GP - New	$300	$61.80
	10960	Physio Care Plan from GP - Review	$195	$61.80
		Initial Pessary + Pessary Fitting	$200*	N/A
* in addition to consult fee		Pessary Replacement	$100*	N/A
PELVIC FLOOR PHYSIOTHERAPY - NAMBOUR
Zoe Mills	500	New Patient	$240	N/A
	505	Review	$170	N/A
	10960	Physio Care Plan from GP - New	$240	$61.80
	10960	Physio Care Plan from GP - Review	$170	$61.80
		Initial Pessary + Pessary Fitting	$200*	N/A
* in addition to consult fee		Pessary Replacement	$100*	N/A
DIETETICS
Kelsey Riachi Amelia Weddell	500	New Patient (50 minutes)	$240	N/A
	600	Review (50 minutes)	$200	N/A
	600	Review (30 minutes)	$140	N/A
	82350	Eating Disorder Management Plan - New	$240	$61.80
	82350	Eating Disorder Management Plan - Review	$200	$61.80

Cancellation Policy

CANCELLATION POLICY

I understand that failure to attend a scheduled appointment, rescheduling or cancellation within 48 hours of my appointment will incur a cancellation fee equivalent to the full appointment fee.

NURSE PRACTITIONER CONSULTS ARE NOT CHARGED A CANCELLATION FEE.

I understand. I have read and agree to the Cancellation Policy described above. *

I authorise QLD Pelvic Floor Centre to charge my credit card in accordance with the Cancellation Policy described above. *

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Privacy Policy

Due to the Federal Privacy Act 1988, we require your written consent to collect personal information about you. Please read this information carefully and sign where indicated below.

We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose and treat you. We may need to collect information from previous doctors, health care workers, pathology or x-ray services that you have consulted with, for the primary purpose of providing quality health care. This means that we will use the information you provide in the following ways:

Best assess your health care needs and provide medical treatment.
Administration purposes in running our practice. We may need to contact you using phone numbers provided by you.
Billing purposes and debt collection, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your care, including treating doctors, specialists and hospital booking staff outside this practice. This may occur through referral to other doctors, surgery at hospitals, or for medical tests and in the reports or results returned to us following the referrals.
Collection of data for research purposes. This information is used to improve our treatment protocals, which will enable us to improve our quality of care. The data is kept in a secure manner and only the staff involved in the research has access to them. You may be contacted sometime in the future for follow up purposes. No information that can be used to identify you will be included in any publication of the research results. You may withdraw from the research at any time.
You may be contacted for follow up in the future to ensure the long term results of your procedure
Our practitioners use AI software to accurately and efficiently document your consultation. This software assists with capturing necessary details for your medical records and supports, but does not replace, your clinician's judgment. Your consent is essential for its use, and you have the right to opt-out at any time. For more detailed information, or to opt-out, please advise reception on your arrival.

I am aware of my right to access the information collected about me, except in some circumestances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.

Full Name *

Today's Date *

I have read and understand the Privacy Policy detailed above and voluntarily agree to the terms and conditions listed. *

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Signature of Patient

THANK YOU

Just hit the SUBMIT button below and you are all done!! Our friendly reception team will be in touch with you very soon!!

In the interim, if you have any queries or concerns, please do not hesitate to contact the rooms on (07) 3193 7711.