form test

Name of your Urologist
Your Details
Title
Gender*
If selected 'Other', please specify*
Hidden
Name
First Name Middle Name Last Name
First Name*
Middle Name
Last Name*
Known As
DOB*
DD slash MM slash YYYY
Occupation
Email
Address*
Street Address Address Line 2 City State Postcode Country
Mobile Phone
Work Phone
Home Phone
Medicare Number
Reference Number
The number before your name
DVA Number
(If applicable)
DVA Card Colour
Do you receive an Age Pension or Disability Support Pension?
- Yes
- No
Pension Card Number
Please present your Pension Card at the front desk when settling your account.
Expiry Date
DD slash MM slash YYYY
Are you of Aboriginal or Torres Strait Islander origin?
- No
- Yes, Aboriginal
- Yes, Torres Strait Islander
Do you use any mobility aids?*
- None
- Walking stick
- Walking frame
- Wheelchair
- Other
Please specify Other Mobility Aid
Private Health Cover
Do you have private (hospital) health insurance?*
- Yes
- No
Fund
Member Number
Level of Private Health Insurance Cover
Have you had this cover for more than 12 months?
- Yes
- No
Emergency Contact/Next of Kin
Name*
First Last
Relationship*
Phone*
Your GP
Name
Suburb
Phone
Attach referral (optional)
Drop files here or
Accepted file types: pdf, doc, docx, jpg, jpeg, png, xls, xlsx, Max. file size: 16 MB.
TIP: If you upload the wrong file, you can delete it and start again by clicking the small red cross next to the file name.
Your Pharmacy
Name
Phone
Address
Street Address Address Line 2 City State Postcode Country
Medical History
Current Medications
Please list below or attach a comprehensive list from your GP or Pharmacist TIP: If you upload the wrong file, you can delete it and start again by clicking the small red cross next to the file name.
Drop files here or
Accepted file types: pdf, doc, docx, jpg, jpeg, png, xls, xlsx, Max. file size: 16 MB.
Do you have any allergies to any medications?
Medical conditions / previous operations
Are you diabetic?*
- Yes
- No
Informed Financial Consent
Consultation Fees – effective 1 April 2023
Urologist Fee Medicare Rebate Out of Pocket Expense (Gap)
Initial Consult $300 $81.30 $218.70
Review Consult $200 $40.85 $159.15
Initial (pensioner*) $210 $81.30 $128.70
Review (pensioner*) $150 $40.85 $109.15

*Aged Pension or Disability Support Pension
Payment for your consultation is expected on the day of service. A debt recovery fee of 20% + GST will apply for outstanding accounts.
A current referral is required for you to claim Medicare rebates. Please note that a referral from a General Practitioner is generally valid for 12 months but may be deemed ongoing if specified by your GP. A referral from a specialist is valid for only 3 months.
DVA Gold Card holders will be billed directly through the Department of Veterans’ Affairs.
If nursing services are required (in the rooms), a non-rebatable fee may apply.
A $20 non-rebatable fee will apply for prescriptions requested outside of appointment time.
To avoid any unnecessary or duplicate testing, kindly forward any relevant pathology and radiology to our rooms prior to your appointment. Please be aware that there are new Medicare restrictions for PSA testing, hence out of pocket pathology fees may apply. PSA testing is an integral part of monitoring prostate disease, and your Urologist will request PSA testing as clinically required.
Consent for Release of Information
It is an increasingly important part of a surgical practice to perform quality assurance projects and these include clinical audits. This means critically looking at procedures that are performed and discussing any issues that may have arisen so that these could be prevented in the future. These audits must be peer reviewed in order for them to be deemed suitable by the Royal Australasian College of Surgeons. As such, some of this information is presented in front of other colleagues and urologists. At no time are patients’ identities mentioned during these discussions but simply a general discussion regarding the type of cases that have been performed and problems that may have arisen. With the current privacy legislation it is imperative that we have your informed consent to perform these audits and that you agree that information that may be obtained from these audits is allowed to be presented in front of third parties such as other urologists.
Our Privacy Policy is available on request.
I agree to the collection, use and disclosure of medical information collected about me by Australian Urology Associates so they may properly assess, diagnose and treat, and be proactive in my health care needs.
Signature*
patient or parent/guardian of patient
Print Name*
Date
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Save and Continue Later

	Urologist Fee	Medicare Rebate	Out of Pocket Expense (Gap)
Initial Consult	$300	$81.30	$218.70
Review Consult	$200	$40.85	$159.15
*Initial (pensioner)**	$210	$81.30	$128.70
*Review (pensioner)**	$150	$40.85	$109.15

Your Details

Private Health Cover

Emergency Contact/Next of Kin

Your GP

Your Pharmacy

Medical History

Informed Financial Consent

Consultation Fees – effective 1 April 2023

Consent for Release of Information