Welcome to The Prostate Clinic! We are pleased to have you as a patient and look forward to providing you with the highest level of care. Please be advised that Dr. Chabert is a private specialist, and consultation fees are payable on the day of your appointment. The cost of a consultation is $300.00, which is claimable from Medicare. We charge AMA rate fees and do not participate in the "No Gap Scheme." All procedures will be billed directly to the patient for submission to their health fund. If you require an estimate of out-of-pocket expenses before your procedure, a quote can be provided upon request.Privacy and Confidentiality The provision of quality health care requires a doctor-patient relationship of trust and confidentiality. Consistent with our commitment to quality care, this practice has developed a policy to protect patient privacy in compliance with privacy legislation. We collect personal information from patients and, at times, from others involved in their health care. This is necessary to provide appropriate medical care and for administrative purposes. To ensure the highest quality and continuity of care, we may share relevant medical information with other health care providers who are part of your medical team. Additionally, our practice will send a letter to all relevant health care providers detailing the treatment provided.Photography & Video Consent If surgical intervention is required, on the day of your surgery, photos or videos of your procedure may be taken for administrative or teaching purposes. Please note that your identity will never be photographed or filmed, and Dr. Chabert will ensure that your privacy is protected in full compliance with privacy legislation. By signing below, you acknowledge and agree to these terms. If you have any questions regarding fees, privacy, or health fund submissions, please speak to our reception team. We appreciate your trust in our care and look forward to assisting you.AI-assisted documentation consent At The Prostate Clinic, we use secure AI technology to assist with documenting consultation notes during your appointment with Dr. Charles Chabert. This helps ensure accurate and efficient record-keeping. All information is kept confidential and reviewed and finalised by Dr. Chabert. The AI does not replace clinical judgement. You may ask questions or opt out of AI-assisted documentation at any time by informing our office prior to your appointment.I acknowledge that I have read and understood the above information regarding consultation fees, privacy, and the potential use of photos/videos for administrative or teaching purposes. I acknowledge that I have been informed of, and consent to, the use of secure AI-assisted documentation during my consultation and to the taking of de-identified photos or videos for administrative or teaching purposes if required, with all information kept confidential, reviewed and finalised by Dr. Chabert, and understand that I may ask questions or opt out where applicable.Signature(Required)Date(Required) Full Name(Required) First Last Address(Required) Street Address City ZIP / Postal Code Email(Required) Phone(Required)Medicare Number(Required)Expiry(Required)Ref No.(Required)Health FundMembership & Ref No.Allergies(Required)Height (cm)(Required)Weight (kgs)(Required)GP(Required)Medications ASPIRIN DISPRIN CARTIA CELEBREX WARFARIN COUMADIN PRADAXA PLAVIX ARIXTRA HEPARIN CLEXANE ANGININE PREDNISONE NITROLINGUAL SPRAY/ PATCHES TESTOSTERONE HORMONE MEDICATIONMedical Condition Please tick the box below if you have any of the following medical conditions.Medical Conditions DIABETES ASTHMA CARDIAC CONDITION CANCER BLOOD DISORDERS EPILEPSY DEMENTIA HIGH BLOOD PRESSURE HEPATITIS HERNIAAny other medical condition (please provide details….)I give permission for my results or medical condition to be discussed with my partner / spouse.Spouse / Partner NameContact NumberSignature of patient /guardian completing the above information(Required)Over the past month, how often have you...Had a sensation of not emptying your bladder completely after you finished urinating?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time 4 Almost alwaysHad to urinate again less than two hours after you finished urinating?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time 4 Almost alwaysStopped and started again several times when you urinated?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time 4 Almost alwaysFound it difficult to postpone urination?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time 4 Almost alwaysHad a weak urinary stream?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time 4 Almost alwaysHad to push or strain to begin urination?(Required) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time 4 Almost alwaysOver the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?(Required) N/A Once Twice 3 times 4 times 5 times or moreFirst TotalQuality of life due to urinary symptoms.If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? (Please tick which best describes how you would feel)(Required) Delighted Pleased Most satisfied Mixed - equally satisfied and dissatisfied Mostly dissatisfied Unhappy TerriblePlease choose the appropriate column for each question about your sexual abilities over the past 4 weeks.How do you rate your confidence that you could get an keep an erection?(Required) Very low Low Moderate High Very highWhen you had erections with sexual stimulation, how often were your erections hard enough for penetration?(Required) Never or almost never A few times Sometimes Most times Almost always or alwaysDuring sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?(Required) N/A Once Twice 3 times 4 times 5 times or moreDuring sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?(Required) N/A Once Twice 3 times 4 times 5 times or moreWhen you attempted sexual intercourse, how often was it satisfactory for you?(Required) N/A Once Twice 3 times 4 times 5 times or moreSecond TotalHow many pads do you use during the day?How many pads do use at night?
