Patient Contract of Engagement: 291 Mental Health Assessment

Fluence Clinic patient contract of engagement
Fluence Clinic is a Telehealth service which is subject to the Privacy Act 1998, and must comply with obligations related to the collection, use and disclosure of personal information. Please refer to our Privacy Policy for more information.

Please read the content in this form carefully. Your informed consent for our service terms, sharing of information, and financial obligations is sought here.

If you have any remaining questions or concerns, please visit our website http://www.fluenceclinic.com/ to view our comprehensive FAQ, or contact Fluence Clinic via hello@fluenceclinic.com before proceeding.
Personal Details
*In order to help us to match the record ACCURATELY, please ensure the NAME, EMAIL ADDRESS and PHONE NUMBER given in this form matches the information you have already provided to us*
First Name*
First Name
Last name*
Last name
DOB*

DayMonthYear
Date
Email*
example@example.com
Phone Number*

Fees
Your 291 Mental Health Assessment Upfront Cost: $975*

The cost of an initial assessment is $975* with a Medicare rebate of $444.90, as long as you have not had a previous 291 mental health assessment in the last 12 months. Your out of pocket expenses is $530.10. Once the pre-assessment forms have been completed and payment has been made, our system will automatically send you an online booking link to book your appointment with the psychiatrist.

Your initial assessment includes:

PSYCHIATRIC ASSESSMENT/DIAGNOSIS. A 45-60 minute consultation with a Fluence Clinic senior psychiatrist. The senior psychiatrist will provide a comprehensive report, management and treatment plan that is sent back to your GP.
Consent*

I understand that Fluence Clinic is not a bulk billing Clinic and by clicking submit, I consent to pay all fees upfront for and associated with the services delivered as outlined above. I also agree to apply for my own Medicare rebate on the receipt of the required documentation from Fluence Clinic on the day of my assessment (*Except if you are seeing Dr Devlin or Dr Chikara, Fluence Clinic will rebate you directly the amount to your initial method of payment).I have read, understood and agree to the Fluence Clinic Terms of Use and Privacy Policy - including that Fluence Clinic may contact me via email, SMS or telephone calls in relation to appointments and health services. As part of this, I also consent to Fluence Clinic sharing my information and previous assessments to the allocated treating psychiatrist and where appropriate the psychiatrist is able to share information with other professionals involved in my care.I acknowledge the Fluence Clinic Cancellation Policy (as part of the Terms of Use) and accept that I may be required to pay a Cancellation Fee of $700 if I am in breach of this policy or fail to attend my scheduled appointment time without at least 3 business days' notice.I understand that Fluence Clinic does not provide prescriptions, please ensure that your GP is happy to do so before your appointment with one of our psychiatrist.If you fail to attend your assessment on time, you will be charged for the psychiatrist’s time. Arriving more than 10 minutes late will be considered a no-show, and the full appointment fee will apply. The full 60-minute assessment is required in most cases, and psychiatrists’ schedules do not allow for further delays.All appointment times are scheduled in Melbourne/Sydney time. If you are in a different state, you must adjust accordingly. You will receive a reminder stating your appointment is in 60 minutes, regardless of your local time zone.
Video Consultation Informed Consent
The benefits of having a video consultation can be:
- Reducing the waiting time to see my healthcare professional
- Avoiding the need for me to travel to see my healthcare professional
- Maintaining management of my health when I can't visit my healthcare professional in person.
The risks of having a video consultation can be:
- A video consultation will not be exactly the same and may not be as complete as a face-to-face service.
- There could be some technical problems that affect the consultation.
- My healthcare service uses systems that meet recommended standards to protect the privacy and security of the video consultation. However, it cannot guarantee total protection against hacking or tapping into the video visit by outsiders. This risk is small, but it does exist.
I can make choices about the healthcare I receive via video consultation.
- If the video visit does not achieve everything that is needed, then I will be given a choice about what to do next. This could include a follow-up consultation, either face to face or via video.
- I can change my mind and stop using video consultations at any time, including in the middle of a consultation. This will not affect my right to ask for and receive healthcare.
I agree to have a video consultation with any Fluence Clinic Psychiatrist listed below, in order to get the soonest possible appointment with a psychiatrist.*

YesNo
I agree to have a video consultation with a specific Fluence Clinic Psychiatrist.*
All Information shared with your Fluence Clinic Psychiatrist will be included in the assessment report to the GP, unless the doctor is clearly instructed to redact any sensitive information.
Name of Patient:*
Signature of Patient:*

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Date:*

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Credit Card Authorisation Form
Please specify your payment method:

Bank Transfer - CheapestCredit Card Payment - 2% Charge
As part of our agreement with Square (who provides our online payment terminal), we are required to ask you to complete the following credit card authorisation form. Please note that this is a formality, and your card will not be charged via this method.

To complete payment, please refer to the online payment link or bank transfer options provided in the prebooking email from Fluence Clinic. These are the only accepted payment methods, and payment through this authorisation form is not applicable.

If you have any questions, please don't hesitate to contact us.
Please complete all fields. You may cancel this authorisation at any time by contacting us. This authorisation will remain in effect until cancelled.
Type:

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(as shown on card):
Number:
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Expiry Date (mm/yy):
I, , authorise Fluence Clinic to charge my credit card above for agreed upon services. I understand that my information will be saved to file for future transactions on my account.
Customer Signature:

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Date:

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Current Status:
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Fluence Clinic patient contract of engagement

Personal Details

Fees

Video Consultation Informed Consent

Credit Card Authorisation Form