SKIN EXAMINATIONS

PATIENT INFORMATION FORM AND FINANCIAL CONSENT

PATIENT DETAILS Please tick: Mr Mrs Ms Miss Master Dr

FAMILY NAME BLICK GIVEN NAME (s) Chandler

DOB 02/09/2019 AGE 0

ADDRESS

SUBURB POST CODE STATE

TEL No. (HOME) (MOB) (WORK)

MEDICARE No. 5421049554638888 REF No. 1 EXPIRY

FUND MEMBER No.

PHF Ref No.

EMERGENCY CONTACT: PatientPEM A09021903

CONTACT NUMBER: 0386063195 RELATIONSHIP:

REFERRING DOCTOR'S DETAILS

REFERRING DOCTOR CLINIC NAME

GP DETAILS (If not the referring doctor)

GP NAME 5421049554638888 CLINIC NAME

HEALTH INSURANCE DETAILS

MEDICARE NUMBER 5421049554638888 POSITION NUMBER 1 EXPIRY

VETERAN AFFAIRS No. GOLD OR WHITE CARD HOLDER (Please circle)

PENSION CARD No.

PHOTOGRAPHY
I acknowledge that photography may be taken of body as part of the skin screen consultation and diagnosis purposes.

SIGNATURE: DATE: 24/09/2019

This signature confirms your consent for us to collect this information from you. The information will be used for
administrative, billing and debt collection purposes, and for referral and requests regarding your healthcare. It is routine in
this surgery for the Medical Practitioner to take photos for research and educational perposes. Should your Medical
Practitioner wish to use your information for any other Medical reason, they will discuss this with you during your
consultation.

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 Explanation of Billing - Informed Financial Consent
We request that the fees be paid at the time os the consultation
NOTE: If you do not provide REDIMED with a valid Medicare Card at your appointment, consult fees will apply

GENERAL PRACTITIONER CONSULTATION FEES:

Standard Consult: $66.00 Medicare Rebate: $36.60
Extended Consult $122.00 Medicare Rebate: $70.30

NURSE PRACTITINER CONSULTATION FEES

Initial Consult: $50.00 (Private Fee) Medicare Rebate: $33.80
Subsequent Consult $25.00 (Private Fee) Medicare Rebate: $17.85
This signature confirms your consent for REDIMED to Bulk Bill your consultation fee to Medicare. (Only if you bring a valid
Medicare card). It also confirm that you have read and understand the above statements, fees, charges and conditions of
Bulk Billing and that you agree with them.

PRINT NAME: Chandler BLICK SIGNATURE: DATE: 24/09/2019

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