TELEHEALTH PAYMENT FORM

TELEHEALTH PAYMENT FORM
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
PAYMENT

It is our policy to be as transparent as possible when it comes to the financial arrangements around care and treatment. The information outlined here is to ensure that you understand the procedure involved in our billing and administrative process. Due to the fact that you are not physically present to pay for your telehealth consults, we are endeavouring to ensure a transparent and streamline system to ensure all payments are processed effectively and responsibly. Any patient receiving care via telehealth is requested to have a credit card on file and have signed the below authorisation for payment to be charged at the time of appointment. This ensures that the practitioner receives reimbursement for their services and reception are then able to immediately email your receipt.
MEDICARE

Medicare rebates have been made available for some telehealth services during this period of COVID-19 isolation. Rebates and the amount are dependent on medicare eligibility requirements and vary with consult length, please check our website price list https://www.thehealthlodge.com.au/price-list or contact reception with any questions regarding eligibility and rebate rates. Your payment details will be sent to Medicare at the time of payment and Medicare will process your rebate directly into your bank account within 24-48 hours.
SESSION PRICING

Session prices will always be quoted to you upon booking and are regularly updated on our online price list. Please note prices are subject to change but we endeavour to inform all our clients of any price changes as they occur. Price list: https://www.thehealthlodge.com.au/price-list
SUPPLEMENT AND DISPENSARY PRICING

We endeavour to always quote you accurate supplement and shipping prices but please note that these can change due to external factors coming directly from the supplier. If you are concerned about the cost of the supplements being prescribed, please inform your practitioner so that they can have our dispensary team call you before charging and shipping.
MISSED SESSIONS

Due to unforeseen circumstances, you may need to cancel or reschedule your appointment with us, we request 24 hours’ notice to change or cancel an appointment, to allow us appropriate time to offer the appointment time to other patients awaiting treatment. We request you endeavour to let us know if you cannot attend a scheduled session, any notice is always better than no notice. If you cancel or reschedule your appointment within 24 hours a cancellation fee will be charged. Same day cancellation or non-attendance will incur a charge of the full appointment fee.
OUR COMMITMENT

It is our aim and focus to support you in your healing journey. We endeavour to provide the highest quality of treatment and service. Your decision to allow us to assist you in your healing journey is one we take seriously. We strive to continually provide you with exceptional care and transparent administrative process. If you have any questions regarding the information outlined here, please contact our team via phone on 6685 6445 or email us on info@thehealthlodge.com.au
CONSENT

Telehealth Appointments -- please complete one of the below fields
I FULL NAME consent for The Health Lodge to process full payment on the credit card I have provided on completion of my telehealth session.
Name*

First NameLast Name
Signature*

Clear
CREDIT CARD INFORMATION - If you prefer you can provide over the phone.
CONSENT

Dispensary and Supplementation
Would you like Dispensary to contact you with supplement fees before processing? If YES, we will call you to confirm charges and payment processing If NO, please sign the below consent.*

YesNo
IFULL NAME consent for The Health Lodge to process full payment of my prescribed supplements on the credit card I have provided on completion of my telehealth session.
Name*

First NameLast Name
Signature*

Clear
Should be Empty:

TELEHEALTH PAYMENT FORM

PAYMENT

MEDICARE

SESSION PRICING

SUPPLEMENT AND DISPENSARY PRICING

MISSED SESSIONS

OUR COMMITMENT

CONSENT

CONSENT