Online Forms

Patient Data Sheet

Please complete using BLOCK LETTERS.



    The cost of consultation is above the Medicare schedule fee. This means you will not recover the full fee after claiming from Medicare. Accounts are payable at the time of consultation.There may be additional charges for procedures undertaken (i.e Injection etc.). Any 'out-of-pocket' cost related to procedures need to be paid before the procedure date. Procedures will have to be rescheduled; otherwise.

    Any unpaid accounts for consultation or surgery will be sent to our debt collectors and you will be responsible for all fees incurred
    I have read the above and agree to abide by the payment terms of this practice.
    I consent to all or any of the above information to be released to other health providers, next of kin and agencies during the course of my treatment.