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RHW Physio self-referral online booking form
Patient details
Last/Surname
First/Given Name
Email address
Postcode:
Date of Birth
Date
Aboriginality Status
- None -
Aboriginal
Aboriginal and Torres Strait Islander
Neither Aboriginal or Torres Strait Islander
Torres Strait Islander
Not Known
Country of Birth
Language spoken at Home
Interpreter Needed
- None -
Yes
No
Reason for Referral
- Select a value -
Bladder or bowel leakage, urgency or difficulty emptying
Vaginal symptoms (including prolapse)
Sexual pain or problems
Exercise during cancer treatment
Lymphoedema related to cancer
Back or pelvic girdle pain
Pain associated with endometriosis or menstrual periods
Exercise for gestational diabetes
Other
Are you currently accessing other services on the Randwick Campus?
- None -
Yes, breast cancer services
Yes, gynaecology cancer services
Yes, I am pregnant and having a baby at The Royal
Yes, I have recently (last 12 months) had a baby at The Royal
Yes, prostate cancer services
Yes, menopause service
Yes, gynaecology outpatient department
Yes, the service I am accessing is not listed
No, I am not accessing any services and live in the local community
No, I live out of area and don't have a local pelvic health service
What you are hoping to see a physiotherapist for
Have you seen us before?
- None -
Yes
No
Appointment preferences
Please indicate your preferred days and times to attend physiotherapy
Preferred days to attend physiotherapy?
Monday
Tuesday
Wednesday
Thursday
Friday
Please indicate your preferred time to attend appointments?
Mornings before 10am
Mornings after 10am
Afternoons before 3pm
Afternoons after 3pm
Soonest possible appointment
Would you prefer to attend your appointment in person or online?
- None -
In person
Online
Whichever is recommended
What else we can do to help you access or attend physiotherapy?
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