PATIENT DETAILS:

NEXT OF KIN:

REFERRAL DETAILS:

 

ACCOUNT DETAILS:

Please note: If you are a member of NIB, please expect to pay surgical fees in full upfront due to the restrictions imposed by your health fund.

Consultation Fees: Initial Consult Subsequent Consult

Mr Frank Lin $170.00 (Medicare Rebate $76.15) $80.00 (Medicare Rebate $38.25)

Dr Neela Janakiramanan $210.00 (Medicare Rebate $76.15) $80.00 (Medicare Rebate $38.25)

Aged Pension card holder rates are available.

All fees must be settled at the time of presentation of the account.
Procedures undertaken in our rooms will attract a facility fee for materials and instruments.

WORKCOVER

If a Workcover/TAC account is not settled within 30 days it becomes the responsibility of the patient.

GENERAL HEALTH QUESTIONNAIRE

MEDICAL CONDITION - Heart

MEDICAL CONDITION - Diabetes

MEDICAL CONDITION - DVT / PE

MEDICAL CONDITION - Allergies

CLINICAL PHOTOGRAPHY

Clinical photographs and are a valuable resource in providing a high level of health care. Eastern Plastic Surgery routinely uses clinical photos for record keeping, tracking your progress/recovery, and for educating other patients and health care professionals. Your photo constitutes part of your confidential medical records and is stored securely in accordance with Federal and State Legislations. Other than for record keeping, your photos will be de-identified and your name and personal details will never be used.

If you do not consent to clinical photographs to be part of your treatment please inform the Practice Manager.

PRIVACY STATEMENT

In order to comply with Federal and State Privacy Legislations, we require your consent to collect personal information about you. Information collected is used for the main purpose of providing quality health care and may be used for administrative and billing purposes. It may be disclosed to others involved in your health care, including, but not limited to, other treating doctors, hospitals, health care related services, medical diagnostic services and your GP/referring doctors.

I have read the above information and give consent to the collection of my personal information by Eastern Plastic Surgery.