Patient Registration Form

PATIENT DETAILS

PATIENT CONTACT DETAILS

NEXT OF KIN / EMERGENCY CONTACT DETAILS

REFERRING DOCTOR TO US

MEDICARE

If you use a different name please write the name & surname

PRIVATE HEALTH INSURANCE

TAC/WORKCOVER

PENSION / HCC/DVA Card

(mm/yyyy)

REASON FOR VISIT

SIGNATURE

PRIVACY POLICY

We require your consent to collect personal information about you. This policy details how and why this information is collected and stored; please read it carefully. Information is collected from you for the primary purpose of providing high quality care as part of your assessment and management plan. Your personal information is predominantly used for administrative purposes in running our medical practice such as billing in compliance with Medicare and the Health Insurance Commission. We also use phone numbers and email provided to either contact you or your next of kin should the need arise. 

Your personal information may be disclosed to others involved in your healthcare, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports of results returned to us following the referrals. You are not obliged to provide any of the information requested, but failing to do so might compromise the quality of the healthcare and treatment we provide. You have the right to access the information we have collected about you, except in rare circumstances where access might legitimately be withheld; an explanation will be provided in such circumstances.

Mr Dissanayake utilises an Australian based and regulated artificial intelligence scribe that convert speech to text during your consultation so Mr Dissanayake can focus on you, and allows for prompt communication with your health practitioners and yourself following your appointment. If you'd prefer this not to be used, please let Mr Dissanayake know.

MR DISSANAYAKE'S FEES FOR PROVISION OF SERVICE

The running cost of an efficient and reliable private surgical practice tailored to your needs requires fees greater than the Medicare rebates. As a result there are out of pocket fees associated with our services. We do not bulk bill Medicare for your accounts.

Private health insurance does not contribute to the costs of outpatient consultations but does make significant contributions to the cost of inpatient surgery. You will be given an invoice after your consultation, at which time settlement is expected and appreciated. Accounts are itemised and are above the standard Medicare rebate. Payments can be made by credit card, EFTPOS, or cash. 

If WorkCover or TAC claim is denied or insufficient information is provided to enable billing, the patient will be responsible for all medical fees associated with treatment.

If you require surgery, you will be given a quote which will include item number or numbers for your procedure. The quote for the total cost of surgery is payable prior to the date of surgery. Our surgical fees are recommended by current medical guidelines. Our goal is to provide high quality healthcare while making every effort to minimise your cost.

Initial Consultation fee is $220 (Medicare rebate: $86.15).

YOUR CONSENT:

PRIVACY POLICY: I have read and understand the requirements outlined in the privacy policy of this medical practice as detailed above, and give my consent for my information to be used in this manner. 

FEES FOR PROVISION OF SERVICES: I have read and understand the Fees For Provision of Services listed. I understand that unless otherwise stated there is no Medicare or health fund rebate to cover the cost of these fees.

FINANCIAL CONSENT: I understand that there are out of pocket expenses associated with surgery. These expenses may include surgical and anaesthetic costs that are not fully refundable by either Medicare or health insurance funds. 

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