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Patient Registration Form

Medical History

i.e. intra-cranial aneurysm clips, cardiac pacemaker, coronary stents, intra ocular foreign bodies, cochlear implants or other? If so, please describe and include the implant date

Lifestyle

Consent

Information about fees

Please note that this practice does not bulk bill for consultations by the doctor. You will be required to pay the fee for the consultation before leaving the practice.

All surgical fees for in hospital procedures may not be covered TOTALLY by your health fund. The reception staff, upon notification of you requiring a procedure, will provide a quote showing the expected item numbers to be used, and the gap (if any) that may be required to be paid by you.

This Gap Payment will be required to be paid prior to any procedure unless otherwise informed.

Please be aware that some health funds do not allow us to bill them directly if a gap on a procedure has been charged. Our staff will advise you if your Health Fund is one of these. You will then be responsible for the total of all fees to be charged for your procedure and required to pay the fees in full prior to your procedure date.

Please note that Anaesthetists fees are entirely separate to any billings from NQ Vascular Townsville for procedures. Contact numbers for anaesthetists will be provided on all quotes requiring their services and we strongly suggest that you make contact with them and request a quote.

Some surgical procedures will also require imaging to be taken prior to or during the procedure. Please be aware that you may also receive a bill from QLD X-Ray for their services provided, which you will be required to pay.

I acknowledge full responsibility for all NQ Vascular Townsville consultation fees including any shortfall in reimbursement by my health insurance provider and Medicare.

Furthermore, I consent to ultrasound imaging as deemed appropriate by NQ Vascular and it’s principle for diagnostic purposes and agree to pay any shortfalls where appropriate.