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        Practitioner Support Intake Form

        Practitioner Support - Patient Information Assessment

        "*" indicates required fields

        Step 1 of 10

        10%

        1/10: Nuts and bolts

        Your Email Address*
        Your Name*

        Patient Information

        Patient has:*
        Approximate BMI*

        2/10: Goals

        3/10: The vagina and urinary tract

        Urinary tract symptoms*
        Symptoms include*
        Vaginal symptoms*
        During menstruation, symptoms:*
        Vaginal symptoms include:*
        Odour*
        Discharge*
        The pain is around the:*
        The itch is around the:*
        Vaginal pH*
        In the past year, the patient has been diagnosed with:*
        Patient has a history of*
        Patient has had symptoms for*

        4/10: A little bit of context

        Patient has used Accutane (isotretinoin) acne drug*
        Patient uses antihistamine medication*

        5/10: What's going in

        Diet*
        Diet choices*

        6/10: Digestive

        Are there digestive symptoms?*

        7/10: The invisible forces

        Energy levels*
        Sleep quality*
        Stress and anxiety levels*

        8/10: Hormonal cycles

        Menstrual status*
        Hormonal birth control
        Menstrual patterns
        Premenstrual symptoms include:
        Diagnosed with or suspected of having:

        8/10: Crunching the numbers - please obtain patient consent before sharing files

        My patient has provided consent to securely share their files*
        Your patient files are held in strictest confidence according to Australian law, held securely and deleted after the consultation. My Vagina DOES NOT keep non-patient healthcare files on record, but DOES keep consultation notes on the patient and practitioner for our records.
        Drop files here or
        Max. file size: 12 GB.
          All your patient files are deleted after the consultation, however a file will be created with the notes of the consultation.
          Drop files here or
          Accepted file types: pdf, Max. file size: 12 GB.
            Drop files here or
            Accepted file types: zip, Max. file size: 12 GB, Max. files: 1.
              We can screen your DNA test for a handful of key markers These results are only used for support purposes. Please log into your provider's website and download the raw data file and upload here. Only accepted format is .zip.

              9/10: Almost there!

              10/10: Well done! Just one last thing...

              Consent to disclaimer*
              Please note this disclaimer is a complex legal document. It essentially means that outside of Australia (where we are bound by Australian law) My Vagina and its practitioners and staff are not legally responsible for what happens to you or your patients, and you engage with us and follow our recommendations at your own risk.

              In saying this, we are qualified practitioners operating within the legal framework of Australia, and we take this very seriously! We will work hard for you and your patients within our capabilities and provide a high level of care.

              MISCELLANEOUS LIMITATION OF LIABILITY
              The client agrees they use My Vagina’s services at their own risk.

              Client releases My Vagina, its officers, employees, directors, subsidiaries, principals, agents, heirs, executors, administrators, successors, assigns, instructors, guides, staff, participants, naturopaths, practitioners and related entities any way as well as the venue where the sessions are being held (if applicable) and any of its owners, executives, agents, or staff (hereinafter “Releasees”) from any and all damages that may result from any claims arising from any agreements, all actions, causes of action, contracts, claims, suits, costs, demands and damages of whatever nature or kind in law or in equity arising from my participation in the consultations.

              Client accepts any and all risks, foreseeable or unforeseeable.

              Client agrees that My Vagina will not be held liable for any damages of any kind resulting or arising from including but not limited to; direct, indirect, incidental, special, negligent, consequential, or exemplary damages happening from the use or misuse of My Vagina’s services or enrolment in the Program.

              My Vagina assumes no responsibility for errors or omissions that may appear in any of the materials.

              INFORMATION PROVIDED
              All your personal and private medical information will be kept confidential under Australian medical laws.

              We will use your information to improve your care using a variety of tools.

              JURISDICTION
              Your use of the My Vagina website and services and any dispute arising out of your use of it is subject to the laws of the Commonwealth of Australia.

              These terms are governed by the laws of the Commonwealth of Australia and subject to the exclusive jurisdiction of the courts operating in Australia.

              My Vagina’s website and resource materials may be accessed throughout Australia and overseas.

              We make no representation that My Vagina’s website complies with the laws (including intellectual property laws) of any country outside Australia.

              If you access My Vagina’s website from outside Australia, you do so at your own risk and are responsible for complying with the laws in the place where you access My Vagina’s website and services.
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              176 High St, Northcote, 3070, Victoria, Australia

              • Popular Topics
                • Aerobic vaginitis (AV)
                • Bacterial vaginosis (BV)
                • Urinary tract infections (UTIs)
                • Vaginal yeast infections and thrush
                • Treat vaginal cracks, cuts and tears
                • Browse My Vagina articles!
              • Shop
              • About Us
              • Support
                • Contact My Vagina
                • Treatment instructions
              • My Programs
                • All Programs
                  • Killing BV Vagina Treatment Program
                  • Killing BV Penis Treatment Program
                  • Perimenopause Survival Kit with Simone Jeffries
              • Ask Aunt Vadge
              • Schedule Consultation
              • Practitioner
                • Apply for Practitioner Access
              • Login
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