{"id":6886,"date":"2018-05-17T03:47:52","date_gmt":"2018-05-17T03:47:52","guid":{"rendered":"http:\/\/www.perthmenshealth.com.au\/?page_id=6886"},"modified":"2022-06-06T10:25:07","modified_gmt":"2022-06-06T10:25:07","slug":"new-patent-form","status":"publish","type":"page","link":"https:\/\/www.perthmenshealth.com.au\/?page_id=6886","title":{"rendered":"New Patient Form"},"content":{"rendered":"<p>\n\n\n<section id=\"section_id-16886\" class=\" fw-main-row-custom fw-main-row-top fw-section-image fw-section-no-padding\" style=\" background-image:url(https:\/\/www.perthmenshealth.com.au\/wp-content\/uploads\/2018\/03\/cblue.jpg);\" >\n\t<div class=\"fw-container\">\n\t\t<div class=\"fw-row\">\n\t<div class=\"fw-col-xs-12\">\n\t<h2 style=\"font-family: 'Lato', sans-serif; font-size: 50px; font-weight: 900; line-height: 1; text-align: center; padding-top: 1em; padding-bottom: 1em; height: 100%;\"><strong>Patient Information Form<\/strong><\/h2><\/div>\n<\/div>\n\n\t<\/div>\n<\/section>\n\n\n<section id=\"section_id-26886\" class=\" fw-main-row fw-section-no-padding\" style=\" \" >\n\t<div class=\"fw-container\">\n\t\t<div class=\"fw-row\">\n\t<div class=\"fw-col-xs-12\">\n\t\n\t<div class=\"fw-divider-space\" style=\"padding-top: 80px;\"><\/div>\n<\/div>\n<\/div>\n\n\t<\/div>\n<\/section>\n\n\n<section id=\"section_id-36886\" class=\" fw-main-row-custom fw-section-no-padding\" style=\" \" >\n\t<div class=\"fw-container\">\n\t\t<div class=\"fw-row\">\n\t<div class=\"fw-col-xs-12\">\n\t<h3 style=\"font-family: 'Lato', sans-serif;\">Patient Information Form<\/h3><p>Complete the fields below and click SUBMIT and an email with your details will be sent to Perth Mens Health OR Click <a href=\"https:\/\/www.perthmenshealth.com.au\/wp-content\/uploads\/2022\/06\/NP_forms_2022.pdf\"><strong>here<\/strong><\/a> to download a PDF of the form to print out and complete to take to your first appointment.<\/p><\/div>\n<\/div>\n\n\t<\/div>\n<\/section>\n\n\n<section id=\"section_id-46886\" class=\" fw-main-row fw-section-no-padding\" style=\" \" >\n\t<div class=\"fw-container\">\n\t\t<div class=\"fw-row\">\n\t<div class=\"fw-col-xs-12\">\n\t\n\t<div class=\"fw-divider-space\" style=\"padding-top: 50px;\"><\/div>\n<\/div>\n<\/div>\n\n\t<\/div>\n<\/section>\n\n\n<section id=\"section_id-56886\" class=\" fw-main-row-custom fw-section-no-padding\" style=\"background-color:#e6e5e5; \" >\n\t<div class=\"fw-container\">\n\t\t<div class=\"fw-row\">\n\t<div class=\"fw-col-xs-12\">\n\t<p><div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f7199-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F6886#wpcf7-f7199-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"7199\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.5.6.1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f7199-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"redirect_nonce\" value=\"d1cee19f40\" \/>\n<input type=\"hidden\" name=\"wpcf7cfpdf_hidden_name\" value=\"document-pdf\" \/>\n<input type=\"hidden\" name=\"wpcf7cfpdf_hidden_reference\" value=\"766ca098\" \/>\n<input type=\"hidden\" name=\"wpcf7cfpdf_hidden_date\" value=\"11032026\" \/>\n<\/div>\n<link rel=\"stylesheet\" href=\"https:\/\/www.perthmenshealth.com.au\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/css\/frontend.css\" \/><script type=\"text\/javascript\" src=\"https:\/\/www.perthmenshealth.com.au\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/js\/frontend.js?ver=2.2.7\"><\/script><p>Please complete the New Patient Information Form<\/p>\n<style type=\"text\/css\" id=\"wp-custom-css\">\ntd {font-size: 100%; line-height: 1em;}\ntd label {color:#705208; padding-top: 2em;}\ninput {width: 100%; }\ninput[type=checkbox] {width: 2em; }<\/p>\n<p>.small {font-size: 60%;line-height: 1;}\n.medium {font-size: 80%;line-height: 1; }\nol {margin-top: 1em; margin-left: 2em; font-size: 80%; line-height: 1.5;}\n.medium2 {font-size: 80%;line-height: 1; color: brown; margin-left: 1em; }\n.medium .right {line-height: 1; border: margin-left: 2em; list-style-position:outside;}\n.right li {padding:0.5em 0 0 0;}\n.wpcf7-list-item-label {color:#705208;}\n.wpcf7-form-control-wrap.Howdidyourhearaboutus.wpcf7-checkbox{display:inline;}<\/p>\n<p>input[type=\"radio\"]{<\/p>\n<p>}<\/p>\n<p>.radio {\nborder: 1px solid red;\nheight: 20px;\n}<\/p>\n<p>.lineup {\ndisplay: inline;\nborder: 1px solid red;\n}<\/p>\n<\/style>\n<table width=\"100%\" >\n<tbody>\n<tr>\n<td> <label>Title<\/label> <\/td>\n<td> <label>Surname<\/label> <\/td>\n<td> <label>Given Names<\/label> <\/td>\n<td>&nbsp;  <\/td>\n<\/tr>\n<tr>\n<td> <span class=\"wpcf7-form-control-wrap title\"><input type=\"text\" name=\"title\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td> <span class=\"wpcf7-form-control-wrap surname\"><input type=\"text\" name=\"surname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td> <span class=\"wpcf7-form-control-wrap given-names\"><input type=\"text\" name=\"given-names\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td>&nbsp;  <\/td>\n<\/tr>\n<tr>\n<td> <label>Date of birth<\/label> <\/td>\n<td> <label>Mobile or preferred contact number<\/label><\/td>\n<td>&nbsp;  <\/td>\n<td>&nbsp;  <\/td>\n<\/tr>\n<tr>\n<td> <span class=\"wpcf7-form-control-wrap date-of-birth\"><input type=\"text\" name=\"date-of-birth\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td><span class=\"wpcf7-form-control-wrap mobile\"><input type=\"text\" name=\"mobile\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>&nbsp;  <\/td>\n<td>&nbsp;  <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> <label>Residential Address<\/label> <\/td>\n<td> <label>Suburb<\/label> <\/td>\n<td> <label>Postcode<\/label> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> <span class=\"wpcf7-form-control-wrap residential-address-1\"><input type=\"text\" name=\"residential-address-1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>   <\/td>\n<td> <span class=\"wpcf7-form-control-wrap suburb\"><input type=\"text\" name=\"suburb\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td> <span class=\"wpcf7-form-control-wrap postcode\"><input type=\"text\" name=\"postcode\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> <label>Preferred Postal Address<span class=\"medium2\"> (If different from above) <\/span><\/label><\/td>\n<td> <label>Suburb<\/label> <\/td>\n<td> <label>Postcode<\/label> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" > <span class=\"wpcf7-form-control-wrap preferred-postal-address-1\"><input type=\"text\" name=\"preferred-postal-address-1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>   <\/td>\n<td> <span class=\"wpcf7-form-control-wrap suburb_2\"><input type=\"text\" name=\"suburb_2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td> <span class=\"wpcf7-form-control-wrap postcode_2\"><input type=\"text\" name=\"postcode_2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> <label>* Email address<\/label> <\/td>\n<td>&nbsp;  <\/td>\n<td>&nbsp;  <\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<p>    <span class=\"wpcf7-form-control-wrap your-email\"><input type=\"email\" name=\"your-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n<span class=\"medium2\">(Please only provide email if it can be used by this practice when necessary)<\/span><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> <label>Next of Kin <span class=\"medium2\">(For Emergency purposes only)<\/span><\/label> <\/td>\n<td colspan=\"2\"> <label>Next of Kin contact details:<\/label>\n  <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> <span class=\"wpcf7-form-control-wrap next-of-kin\"><input type=\"text\" name=\"next-of-kin\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td colspan=\"2\"> <span class=\"wpcf7-form-control-wrap next-of-kin-contact\"><input type=\"text\" name=\"next-of-kin-contact\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\"> <span class=\"medium2\">(If you do not want to fill in the Next of Kin details, please put N\/A)<\/span><\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\">  <\/td>\n<td>  <\/td>\n<td>&nbsp;  <\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">&nbsp;<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<hr><\/td>\n<\/tr>\n<tr>\n<td > <label>Medicare Card Number<\/label> <\/td>\n<td > <label>Reference No<\/label> <\/td>\n<td > <label>Expiry Date Month<\/label> <\/td>\n<td > <label>Expiry Date Year<\/label> <\/td>\n<\/tr>\n<tr>\n<td> <span class=\"wpcf7-form-control-wrap medicare\"><input type=\"text\" name=\"medicare\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td> <span class=\"wpcf7-form-control-wrap refnumber\"><input type=\"text\" name=\"refnumber\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td> <span class=\"wpcf7-form-control-wrap ex-date-month\"><input type=\"text\" name=\"ex-date-month\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td> <span class=\"wpcf7-form-control-wrap ex-date-year\"><input type=\"text\" name=\"ex-date-year\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> <label>Dept of Veterans Affairs Number<\/label> <\/td>\n<td> <label>Card Colour<\/label> <\/td>\n<td>&nbsp;  <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> <span class=\"wpcf7-form-control-wrap dept-of-veterans-affairs-number\"><input type=\"text\" name=\"dept-of-veterans-affairs-number\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td> <span class=\"wpcf7-form-control-wrap card-colour\"><input type=\"text\" name=\"card-colour\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td>&nbsp;  <\/td>\n<td>&nbsp;  <\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">&nbsp;<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<hr><\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\"><label> How did you hear about us?<\/label> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<span style = \"display: inline-block; position: relative; vertical-align: middle; margin: 5px; cursor: pointer; \"> <span class=\"wpcf7-form-control-wrap hear-about\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"hear-about[]\" value=\"Website\" \/><span class=\"wpcf7-list-item-label\">Website<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hear-about[]\" value=\"Facebook\" \/><span class=\"wpcf7-list-item-label\">Facebook<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hear-about[]\" value=\"Advert\" \/><span class=\"wpcf7-list-item-label\">Advert<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"hear-about[]\" value=\"Word of Mouth\" \/><span class=\"wpcf7-list-item-label\">Word of Mouth<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"hear-about[]\" value=\"Doctor Referral\" \/><span class=\"wpcf7-list-item-label\">Doctor Referral<\/span><\/span><\/span><\/span><\/p>\n<p><\/span>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">&nbsp;<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<hr><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\">  <\/td>\n<td>  <\/td>\n<td>&nbsp;<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\"> If your GP is not your referring doctor, would you like them to receive of copy of the appointment details?\" <\/td>\n<\/tr>\n<tr>\n<td><\/td>\n<td>  <\/td>\n<td>\n<span class=\"wpcf7-form-control-wrap group3\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"radio\" name=\"group3\" value=\"Yes\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"group3\" value=\"No\" checked=\"checked\" \/><\/span><\/span><\/span>\n<\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\" > <label>Usual GP's Name<span class=\"medium2\"> Please only provide details if you give permission for your GP to receive a copy of appointment details etc.<\/span><\/label> <\/td>\n<td> <label>Suburb<\/label> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> <span class=\"wpcf7-form-control-wrap usual-gp\"><input type=\"text\" name=\"usual-gp\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td> <span class=\"wpcf7-form-control-wrap gp-suburb\"><input type=\"text\" name=\"gp-suburb\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td>&nbsp;  <\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">&nbsp;<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<hr><\/td>\n<\/tr>\n<td colspan=\"4\">&nbsp;      <\/td>\n<tr>\n<td colspan=\"4\"> <span class=\"medium\">Perth Men\u2019s Health is a private billing practice. Payment is required at the time of consultation for all patients and most services include a Medicare rebate which can be processed at the time of payment. Please do not hesitate to discuss fees\/Medicare rebates with our reception staff.  <\/span>    <\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">&nbsp;<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<hr><\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<h4>CONSENT FORM<\/h4>\n<p><span class=\"medium\"><br \/>\nIt is the policy of this practice to ensure the confidentiality and security of the personal and health information of those attending.  It is also the policy of the practice to abide by the requirements of the Privacy (Private Sector) Amendment Act 2000.<\/span><br \/>\n<span class=\"medium\"><br \/>\nIt is necessary to collect personal information from you for the primary purpose of assisting the development of diagnosis, treatment and further advice concerning a particular health condition, suspected health condition or circumstance relating to health. The personal and health information collected will be used in the following areas;<\/span><br \/>\n<span class=\"medium\"><\/p>\n<ol>\n<li>Administrative purposes in running the medical practice.<\/li>\n<li>Billing purposes, including compliance with the Health Insurance Commission and Department of Veterans\u2019 Affairs requirements.<\/li>\n<li>Disclosure to others involved in your health care (including treating doctors, specialists and other healthcare professionals outside this medical practice). This may occur through referral to other doctors, referral for medical tests and in the reports or results returned to this practice following referrals.<\/li>\n<li>Disclosure to medical staff of the hospitals where this will be of importance in the furtherance of your health care.<\/li>\n<li>Disclosure for research and quality assurance activities to improve individual and community practice.<\/li>\n<li>Disclosure to legal and insurance enquiries where such evaluations and information is required for the proper conduct, elucidation and compensation of the matter in hand.<\/li>\n<\/ol>\n<p><\/span><br \/>\n<span class=\"medium\">I have read the information provided above and understand the reasons my personal and health information is required to be collected. I am also aware that this practice has a Privacy Policy pertaining to the handling of personal health information of its patients.<\/span><br \/>\n<span class=\"medium\"><br \/>\nI understand that I am not obliged to provide any information requested of me, but that failure to do so might compromise my health care, treatment of \u2013 where applicable \u2013 the proper evaluation of my disability.<\/span><br \/>\n<span class=\"medium\"><br \/>\nI am aware of my right to access the personal and health information collected, except in some circumstances where access might legitimately be withheld. I understand that if my personal and health information is to be used for any other purpose other than set out above, my further consent will be obtained (unless otherwise ordered by a court of law.)<\/span><br \/>\n<span class=\"medium\"><br \/>\nIf approved by the doctor of Perth Mens Health, I am happy to obtain requested results via electronical mail (Emailed to the given email address only if listed on page 1).<\/span><br \/>\n<span class=\"medium\"><br \/>\nI consent to the handling of my personal health information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify to this practice.<br \/>\n<\/span><\/p>\n<p><\/br><\/td>\n<\/tr>\n<td colspan=\"4\">&nbsp;      <\/td>\n<\/tr>\n<tr >\n<td colspan=\"3\"> <label>Signed\/Name <\/label> <\/td>\n<td> <label>Date<\/label> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\"> <span class=\"wpcf7-form-control-wrap consent-name\"><input type=\"text\" name=\"consent-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td> <span class=\"wpcf7-form-control-wrap condate\"><input type=\"text\" name=\"condate\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<\/tr>\n<tr >\n<td colspan=\"4\"><label>I have read and agree with the Consent Form conditions<\/label> <\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\">\n<\/td>\n<td colspan=\"2\">\n<p><span class=\"wpcf7-form-control-wrap group5\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"radio\" name=\"group5\" value=\"Yes\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"group5\" value=\"No\" checked=\"checked\" \/><\/span><\/span><\/span>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<p><span class=\"wpcf7-form-control-wrap kc_captcha\" data-name=\"kc_captcha\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"captcha-image\" ><span class=\"cf7ic_instructions\">Please prove you are human by selecting the<span> star<\/span>.<\/span><label><input aria-label=\"1\" type=\"radio\" name=\"kc_captcha\" value=\"bot\" \/><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 576 512\"><path fill=\"currentColor\" d=\"M488 313v143c0 13-11 24-24 24H348c-7 0-12-5-12-12V356c0-7-5-12-12-12h-72c-7 0-12 5-12 12v112c0 7-5 12-12 12H112c-13 0-24-11-24-24V313c0-4 2-7 4-10l188-154c5-4 11-4 16 0l188 154c2 3 4 6 4 10zm84-61l-84-69V44c0-6-5-12-12-12h-56c-7 0-12 6-12 12v73l-89-74a48 48 0 00-61 0L4 252c-5 4-5 12-1 17l25 31c5 5 12 5 17 1l235-193c5-4 11-4 16 0l235 193c5 5 13 4 17-1l25-31c4-6 4-13-1-17z\"\/><\/svg><\/label><label><input aria-label=\"2\" type=\"radio\" name=\"kc_captcha\" value=\"kc_human\" \/><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 576 512\"><path fill=\"currentColor\" d=\"M259 18l-65 132-146 22c-26 3-37 36-18 54l106 103-25 146c-5 26 23 46 46 33l131-68 131 68c23 13 51-7 46-33l-25-146 106-103c19-18 8-51-18-54l-146-22-65-132a32 32 0 00-58 0z\"\/><\/svg><\/label><label><input aria-label=\"3\" type=\"radio\" name=\"kc_captcha\" value=\"bot\" \/><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 640 512\"><path fill=\"currentColor\" d=\"M624 352h-16V244c0-13-5-25-14-34L494 110c-9-9-21-14-34-14h-44V48c0-26-21-48-48-48H48C22 0 0 22 0 48v320c0 27 22 48 48 48h16a96 96 0 00192 0h128a96 96 0 00192 0h48c9 0 16-7 16-16v-32c0-9-7-16-16-16zM160 464a48 48 0 110-96 48 48 0 010 96zm320 0a48 48 0 110-96 48 48 0 010 96zm80-208H416V144h44l100 100v12z\"\/><\/svg><\/label>\r\n    <\/span>\r\n    <span style=\"display:none\">\r\n        <input type=\"text\" name=\"kc_honeypot\">\r\n    <\/span><\/span><\/span><br \/>\n\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<input type=\"submit\" value=\"Send\" class=\"wpcf7-form-control has-spinner wpcf7-submit\" \/><\/p>\n<\/td>\n<\/tr>\n<tbody>\n<\/table>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div><\/p><p>&nbsp;<\/p><p>&nbsp;<\/p><\/div>\n<\/div>\n\n\t<\/div>\n<\/section><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Patient Information Form Patient Information FormComplete the fields below and click SUBMIT and an email with your details will be sent to Perth Mens Health OR Click here to download a PDF of the form to print out and complete to take to your first appointment. Please complete the New [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-6886","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"brizy_media":[],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/www.perthmenshealth.com.au\/index.php?rest_route=\/wp\/v2\/pages\/6886","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.perthmenshealth.com.au\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.perthmenshealth.com.au\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.perthmenshealth.com.au\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.perthmenshealth.com.au\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=6886"}],"version-history":[{"count":26,"href":"https:\/\/www.perthmenshealth.com.au\/index.php?rest_route=\/wp\/v2\/pages\/6886\/revisions"}],"predecessor-version":[{"id":7454,"href":"https:\/\/www.perthmenshealth.com.au\/index.php?rest_route=\/wp\/v2\/pages\/6886\/revisions\/7454"}],"wp:attachment":[{"href":"https:\/\/www.perthmenshealth.com.au\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=6886"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}