Personal Details

Patient first name *

Patient surname *

Date of birth *

Email Address *

Home phone

Mobile phone *

Home address (incl suburb and post code) *

Referred by: *

Private Billing Information

Please note that this is a private billing practice. A $100 pre-paid, non-refundable holding fee is required to confirm your appointment and serves as a cancellation fee in case of non-attendance. This fee is credited towards the total amount, the balance of the consultation fee is to be paid in full at the time of your consultation. Initial consultation fee is $360 before Medicare rebate of $137.65. Review fee is $160 before Medicare rebate of $68.90. Workcover/TAC/DVA must produce a copy of initial consultation approval or pre-payment of the consultation fee above will be requested and a receipt provided for you to liaise with your third-party provider following your appointment.

I understand and agree to the above fee policy. *

Medicare & Private Health Fund Information

Medicare Number

IRN (Number next to your name)

Medicare Expiry

Do you have a Private Health Fund?

YesNo

Do you have Hospital Cover with your Private Health Fund? *

How long have you been with your current health fund? *

Private Health Fund

Membership Number

Reference Number

Expiry date

Are you a DVA Gold member?

YesNo

DVA card number

Do you have a Concession Card?

YesNo

If YES, what is your Concession Card number?

Is this relating to a WorkCover Claim?

YesNo

If YES, what is your WorkCover Claim number?

If this relates to a WorkCover Claim please add WorkCover Insurer + your case manager's name and best contact number

Emergency Contact Information

Emergency Contact *

Phone *

Emergency contact’s relationship to you

Health Information

What is the reason for your consultation?

Please provide your nominated GP's name & practice details for correspondence purposes *

Please list all current specialists involved in your care

Please lists any allied health practitioners involved in your care

I have acknowledged the $100 prepayment to confirm my appointment. A payment link will be sent once you have been given an appointment date. *

Payment disabled. Please configure your payment provider information.

I confirm that above information I have provided is true, complete and accurate. *

Signature

Clear

Date

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