• Confidential Patient Registration

  • Patient Details

  • Date of Birth*
     - -
  • Are you of Aboriginal or Torres Strait Islander origin?
  • Do you use any mobility aids?*

  • Your Health Cover

  • Do you have private (hospital) health insurance?*
  • Have you had cover for more than 12 months?*
  • DVA Number?*
  • *

  • Do you receive a Concession Card or Disability Support Pension?
  • Expiry Date
     - -

  • Emergency Contact

    or Next of Kin

  • Your Referring Doctor

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  • TIP: If you upload the wrong file, you can delete it and start again by clicking the small red cross next to the file name.

  • Your Pharmacy

  • Medical History

  • Current Medications

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  • Are you diabetic?*
  • Would you like your letter to the GP put into your "My Health Record"?*

  • Informed Financial Consent

  • Consultation Fees - effective July 2025

  •   Surgeon Fee Medicare Rebate Out of Pocket
    Expense (Gap)

    Initial Consult

    		 $200 $86.15 $113.85
    Review Consult $110 $43.35 $66.65
    Initial Concession $120 $86.15 $33.85
    Review Concession $70 $43.35 $26.65

  • Payment for your consultation is appreciated on the day of service. For outstanding invoices beyond 21 days that require debt recovery, this will incur an additional fee of 20% + GST.

    A current referral is required for you to claim Medicare rebates. Please note that a referral from a General Practitioner is generally valid for 12 months but may be deemed ongoing if specified by your GP. A referral from a specialist is valid for only three months.

    DVA Gold Card holders will be billed directly through the Department of Veterans Affairs.

    A $20 non-relatable fee for prescriptions requested outside of appointment time will apply.

    To avoid any unnecessary or duplicate testing, kindly forward any relevant pathology and radiology to our rooms prior to your appointment.

  • Consent for Release of Information

    It is an increasingly important part of surgical practice to perform quality assurance projects, including clinical audits. This means critically looking at procedures performed and discussing any issues that may have arisen so that these could be prevented in the future. These audits must be peer-reviewed to be deemed suitable by the Royal Australasian College of Surgeons. As such, some of this information is presented to other colleagues. At no time are patients’ identities mentioned during these discussions but simply a general discussion regarding the type of cases performed and problems that may have arisen.

    Under the current privacy legislation, it is imperative that we have your informed consent to perform these audits and that you agree that information that may be obtained from these audits may be presented to third parties, such as other general surgeons.

     

    Use of Voice‑to‑Text Dictation

    I understand that my clinician may use secure voice‑to‑text dictation technology during my appointment to assist with accurate and timely documentation of my medical care. I consent to the use of this technology for the purpose of creating my clinical notes. 

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    Our Privacy Policy is available on request.

    I agree to collecting, using and disclosing medical information to properly assess, diagnose, treat, and proactively address my health care needs.

  • Date*
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