Patients Information Title * Mr.Mrs.Ms.MissMasterDoctor Gender * FemaleMaleUnspecified First Name * Surname * as appears on Medicare card Preferred Name * Date of Birth * Postal Address * Phone Number (Home) Mobile Number Email * Next of Kin (Name) * Relationship Contact Number Medicare Number Reference Number Expiry Date Private Health Member Number Hospital Cover? YesNo 12 months waiting period served? YesNo Pension Hoder? YesNo Pension Number DVA Card Holder? YesNo DVA Card Number DVA Card Type GoldWhite Usual GP Name Clinic Are you currently on blood thinners, Fish Oil or Diabetic Medication? Please list Privacy Policy Information about your medical and family history is needed to provide accurate medical diagnoses and appropriate treatment. Medical care requires that each member of your medical team has full knowledge of your health information. To ensure the quality and continuity of your health care, your health information may be communicated to or requested from other health care providers from time to time. For billing and medical rebate purposes, some information is provided to account administrators including Medicare, private health funds, the hospital, the anaesthetist, and assistant surgeon. This practice will endeavour to protect your privacy in compliance with the privacy legislation. Privacy Policy Agreement? * I agree to the Privacy Policy Informed Financial Consent Medical expenses incurred as a result of consultations and surgical procedures with Dr Abdullah Rana/Dr Izhar-Ul Haque/Dr Nigel Da Silva are the patient’s responsibility. Full payment is required on the day of the consultation. “Out of pocket” expenses may occur with surgical procedures. These are unfortunately not claimable from Medicare or your health fund. Informed Financial Consent? * I give my Consent Consultation Fees Initial Consultation (104) : $210.00 (Rebate of $81.30 from Medicare). Subsequent Consultation (105) : $110.00 (rebate of $40.85 from Medicare) Any Uninsured (no Private health) or Overseas (No Medicare) accounts will need to be paid in full prior to any procedures and can be provided an itemised receipt for claiming. Personal Health Information Consent I give my consent to Dr Abdullah Rana/Dr Izhar-Ul Haque/ Dr Nigel Da Silva and staff to collect, use and disclose my personal health information for the purpose of providing to me the highest quality and continuity of health care and in expectation that he will do so as practicable in accordance with privacy legislation and the privacy policy of this practice. I give my consent for any medical records be released to Dr Abdullah Rana/Dr Izhar-Ul Haque/Dr Nigel Da Silva. I understand that it is my responsibility to pay any “out of pocket” expenses incurred for my treatment. Consent on Personal Health Information? * I give my consent Your Legal Name * Signature Date * Submit If you are human, leave this field blank. Book an AppointmentTake the first step toward better health today! At Surgical Specialists South Australia, our experienced team is here to provide expert care tailored to your needs. Book your appointment now and let us help you feel your best!