Title
Name
*
First Name
Last Name
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Date of birth
*
MM
DD
YYYY
Home phone number
Mobile phone number
Please tick if you agree to have SMS reminders sent to your phone prior to appointments where possible
SMS Reminder
Work phone number
Occupation
Medicare number
Medicare reference number (on card)
Medicare Expiry date
Private health fund
Private health fund number
Veterans Affairs card
Veterans Affairs card expiry
Pension card / Healthcare card number
Concession expiry
Your GP's name
*
Your GP's contact number
*
Street Address
Suburb
Referral source
Doctor
Hospital
Family friend
Other
Next of kin name
Next of kin's relationship to you
Next of kin mobile number
Next of kin home number
Next of kin work number
Alternative next of kin name
Alternative's contact number
Privacy and consent
*
This practice is committed to ensuring a high-level of privacy and confidentiality. The information I ask you may be rather personal. However, not having it may restrict my capacity to provide you with the standard of medical care that you expect. Medical care requires full knowledge of patient health information by all members of a medical team. To ensure quality and continuity of patient care a patient’s health information may need to be shared with other healthcare providers including doctors and specialists who may become involved in treating you.
This may occur through referral to other doctors and for medical tests. Some information may also be provided to Medicare and private health funds if relevant, for billing and medical rebate purposes. Disclosure to others for medical defence purposes may also be required. Should my health information be required for purposes other than those listed above, I understand that my further consent will be required. I acknowledge that I have read and understand the above Privacy Consent Form.
Fee structure and financial consent
*
Your initial consultation incurs a fee of $340 with a Medicare rebate. (Fees are reviewed every November in accordance with Medicare Australia). Any subsequent consultations (within the 12 month period of your initial referral) will be $170 with a Medicare rebate.
It is your responsibility to ensure your referral is current prior to all consultations.
Payment of your account is requested on the day of your consultation. Payment can be made by Cash, Visa, Mastercard or Eftpos.
If you are Veteran Affairs Gold card holder your consultation account will be sent directly to Veteran Affairs. However, if you require a pessary please be aware that Veteran Affairs does not cover this cost and payment will be required on the day of your consultation.
If you are privately insured, you will be given a quote for any out of pocket costs associated with inpatient admission. If you are admitted as a day or overnight patient at Frances Perry House or Epworth Freemasons, you may be out of pocket for any excess applied by your Health fund. If you do not have private insurance, a quote for inpatient tests and proceedures will be provided to you prior to booking these procedures.
A cancellation fee will apply for any procedures that are either cancelled or altered by you after you have received your booking confirmation.
If you require any prosthesis (such as a pessary) depending on the type of pessary the fees range from $90 to $125 which is not claimable from Medicare or your Health fund. If you do need to undergo surgery you will be sent an itemised quote prior to making a definitive booking.
No surgery date will be made prior to your appointment with Dr Gould.
I accept liability for any services or charges that are incurred as part of my health care and treatment provided by Dr Gould. Prior to undergoing any surgical procedure an itemised estimate of costs will be provided. I understand that any change in my surgery provided by Dr Gould may result in a variation in the original estimation of costs. I have read and understand the above Financial Consent Form and acknowledge and agree to my financial obligations to Dr Gould in undergoing my treatment. I also understand that any surgical accounts are to be finalised within 14 days of surgery.
General information
*
Your general practitioner will continue to be the doctor that you contact for general illnesses and conditions which are not related to your prolapse or bladder problems. If, after your consultation or surgery, you have any questions or concerns you may phone the rooms and speak to our nurse. Our nurse is not available every day, but when she is next in she will return your call. We endeavour to keep to our scheduled appointment times however, circumstances do arise that may cause an unavoidable delay. Whilst we understand it is sometimes necessary to bring children along to your appointment, we have found that children may be intolerant if there are long delays. We seek your consideration of other patients.
