personal details

Required Field*

Mr/Ms/Miss/Mrs*

First name*

Surname*

Date of Birth*

Phone Number*

Address*

Medicare And Private Health Details

Medicare:*

Reference:*

Expiry:*

Health Care or Pension Card:

Expiry:

Dept of Veteran's Affairs Card:

Healthfund:

Number:

Do you have private hospital cover?*

Yes

Have you been in the fund for 12 months

Yes

GP Details

GP Name

Practice Name

Address

Next of Kin

Name*

Relationship

Phone*

Covid Vaccination Status

Triple

Double

Single

No Vaccination

Financial Consent*

I understand that medical expenses (including any gap payments) incurred as a result of consultation or surgical procedure with my Doctor at the Colorectal Surgery are my responsibility. If requested, I will pay my account in full and take full responsibility for claiming costs from the appropriate private health fund. All accounts are payable within 30 days of receipt. If it becomes necessary to use a Debt collection agency to recover monies owed by the undersigned, charges associated with said collection are also the responsibility of the undersigned. Please check with reception staff to confirm the procedures costs of gap payments that may be incurred.

Privacy Policy*

Information about your medical and family health history is needed to provide adequate medical diagnoses and appropriate treatment. Medical care requires that each member of your medical team have full knowledge of your health information. To ensure the quality and continuity of your health care, your health information may be communicated via email and other forms of communication to/from health care providers and required recipients. For billing and medical rebate purposes information is provided to account administrators including Medicare, private health funds, hospitals, anaesthetists and assistant surgeons. This practice will at all times endeavour to protect your privacy in compliance with privacy legislation and our privacy policy (available on request).

Consent*

I give my consent to my Doctor at the Colorectal Surgery and staff to collect, use and disclose my personal health information (via email and other forms of communication) for the purpose of providing the highest quality and continuity of health care in the expectation that this will be implemented as far as practicable in accordance with the privacy legislation and the privacy policy of this practice. In order to arrange operations, tests, or other medical appointments, we need to provide information to other health care providers.

Consultation fees (full payment required on the day unless arrangements made otherwise) this varies depending on Doctor and GAP for procedures.

I agree full payment will be provided initial *

please attach referral Below

My referral is coming directly from my GP/Specialists rooms

Patient Information Form

Please complete the patient information form below and upload your current GP referral.