TeleAbortion Registration & Personal Health History

All your answers to these questions are kept strictly confidential, but they are important for our Consultants to evaluate your suitability and how we will best approach your Tele-Abortion.

Please complete and submit this now. We must have this information before we can commence your first appointment. If you miss the 9 week deadline, unfortunately we will not be able to assist you.

Your Details

If you have a medicare card, please use the name that is on your card so that we can match it to claim your pbs discount on the medication.

We will need to communicate with you via SMS, phone and video call. Note: we do not use facebook messanger.


We will not send anything to your address unless you ask us to. This is purely a legal requirement. Please include your state and postcode.

Have you had any previous pregnancies?
Are you allergic to any medication?

Please include both the name and relationship (eg. friend) along with the best phone number of a person that we can contact in the event of an emergency. Note: It is important that you tell this person about your medical abortion, and when you are planning to do it.

When you submit this form, you will be directed to your Tele-Abortion Consulting Room, where you will asked to create a login on your first visit.

Contact Us

If you have a question, concern, feedback or you just want to get in touch with us, use this form and we'll get back to you as soon as possible. If you'd like a call back, please include your phone number.

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Abortion Online is an initiative of Clinic 66 and Gynaecare Services Pty Ltd  

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