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About
Who we are
Contact
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About
Who we are
Contact
About
Who we are
Contact
×
About
Who we are
Contact
About
Who we are
Contact
×
About
Who we are
Contact
About
Who we are
Contact
×
About
Who we are
Contact
Patient Registration
Title
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Surname
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Given Names
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Same as residential address
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Medicare No.
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Reference Number on card
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Next of Kin: (in case of emergency)
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Contact No: (mobile)
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Parent/Guardian Details: (If patient is under 18 years of age)
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Medicare No.
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DVA (if applicable)
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DVA Card expiry (Gold):
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DVA Card expiry (Orange):
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Private Health Fund (Hospital cover only)
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Referring Doctor
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Usual GP
If not referrer above
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Other Interested Parties?
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How did you hear about us?
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Consultation Fees
FEE POLICY:
All fees are due and payable on the day of consultation. This practice does not routinely bulk bill patients. For details on fees please contact our rooms directly. If you have a valid referral you will receive a Medicare rebate that will be lodged at the time of your appointment.
Additional Fees
Please note that if any procedures are performed during your consultation (e.g. nasal endoscopy, nasal cautery, ear toilet etc.) additional charges may apply. These additional charges may have a Medicare rebate attached to them. If so, they will also be lodged with Medicare at the time of your appointment.
Surgery fees
The costs for any surgical procedures will be discussed, if necessary, with you during consultation.
PRIVACY STATEMENT:
This practice handles personal information in accordance with the Victorian Health Records Act and the Commonwealth Privacy Act. I consent to the handling of my information by this practice for the purpose of providing quality health care, associated administrative and billing purposes. I give permission for my medical information to be obtained from any other source to help with my treatment.
Consent
*
I have read the fee policy and privacy statement.
Contact
PHONE
(03) 9088 8222
FAX
(03) 9088 8223
EMAIL
admin@excelentsurgeons.com.au
Phone (03) 9088 8222
EMAIL
admin@excelentsurgeons.com.au
FAX (03) 9088 8223
CONSULTING LOCATIONS
Excel Camberwell
607–609 Riversdale Road,
Camberwell VIC 3124
Offspring Paediatrics
614 Glenferrie Road,
Hawthorn VIC 3122
