Fee Discount Questionnaire

Fee Discount Questionnaire
The following questions are a broad means test to check eligibility for reduced medical costs. By completing the questionnaire you agree to answering honestly.

Please answer the questions in the order shown so the correct questions are shown.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Are you of Aboriginal or Torres Strait Islander descent?*

YesNo
Are you currently working?*

Yes over $60,000 per yearYes under 60KYes under 45KYes under 30KNo not working
Do you have children?

No1 child2 children3 or more children
Do you receive a Government Aged Pension?*

YesNo
Are you currently studying at university?*

Full Time StudyPart Time StudyNot Studying
Are you aged 12 - 45?*

YesNo
Do you live in a family member's house?*

YesNo
Do you have a Health Care Card?*

YesNo
Do you receive Centrelink or NDIS support?*

Yes, Centrelink support [excluding any Subsidies (eg Childcare), Allowances (eg Carer's) or the Family Tax Benefit]Yes, on NDISYes, both Centrelink and NDISNo
Are you on a Health Care Card?*

YesNo
Do you have children or dependents?*

YesNo
Are you currently experiencing temporary financial hardship?*

YesNo
Please give details*
Do you need ongoing regular financial support from family?*

YesNo
Other mitigating circumstances*
Do you smoke (tobacco or marijuana)*

YesNo
Score
Should be Empty: