Patient Registration Form

Fee Policy : All consultation fees are due and payable on the day of consultation. The practice does not routinely bulk bill patients. Procedures are in addition to the consultation, please refer to the fee schedule for costs. DVA, TAC, and Workcover are also charged at different rates. By signing this form you are agreeing to the practice fee policy.

Privacy Statement: This practice handles personal information in accordance with the Victorian Health Records Act and the Commonwealth Privacy Act. I consent to the handling of my information by this practice for the purpose of providing quality health care, associated administrative and billing purposes. I give permission for medical information to be obtained from any Referring doctor name other sources in order to help with my treatment. Use for teaching, audit research or publication would require additional consent to be obtained.

I have read the above fee policy and privacy statement. I consent to the taking and use of my medical records as described. I have viewed the fees and agree to pay the costs of Contact number consultations and any surgical procedures performed.