Patient registration

Prior to attending your first consultation with Dr Gould please complete this online registration form.

If you would rather complete this form in person, thats fine! We just ask that you please arrive 15 mins prior to your initial appointment to allow for your registration in the rooms.

Please don't hesitate to contact us with any queries you may have regarding your appointment or registration. 

Name *
Name
Home Address
Home Address
Date of birth *
Date of birth
Please tick if you agree to have SMS reminders sent to your phone prior to appointments where possible
SMS Reminder
Concessions
Your GP
Next of kin
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 $250 with a rebate from Medicare of approximately $72.00. (Fees are reviewed every November in accordance with Medicare Australia). Any subsequent consultations (within the 12 month period of your initial referral) will be $125 with a rebate from Medicare of $36.00 Pension & Health Care card holders: Initial consultation $180.00 with a rebate from Medicare of approximately $72.00. Any subsequent consultations (within the 12 month period of your initial referral) will be $90.00 with a rebate from Medicare of approximately $36.00. 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, accounts functional and bladder testing, such as urodynamic studies and cystoscopy will be sent directly to your Health Fund. As you are admitted as a day 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 these tests 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 $75 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 and the quote issued. 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.

Please note: If you have copy of your referral from your GP/Doctor, please email this to us (by either taking a photo or scanning) at office@drfelicitygould.com. If a valid referral is not provided either prior to or on the day of consultation, you will not be entitled to a medicare rebate.