Please enable JavaScript in your browser to complete this form.Title *MrMrsMsMissMasterDrFirst Name *Last Name *Preferred NameDate of Birth *OccupationContact Details Home Phone Number Name of Last Work Phone NumberMobile Phone NumberEmailAddressAddress Line 1Address Line 2City--- Select state ---Please SelectSouth AustraliaWestern AustraliaVictoriaNew South WalesQueenslandTasmaniaAustralia Capital TerritoryNorthern TerritoryState / TerritoryPostalNext of Kin NameFirstLastPhoneRelationshipSelect an optionParentSonDaughterSpousePartnerSiblingRelativeFriendOtherReferring Doctor Name of Referring Doctor *Referring Doctor's Clinic *Is this your usual GP *YesNoPodiatrist Name and ClinicPhysiotherapist Name and ClinicHealthcare Details Medicare Number *Expiry MonthSelect Month010203040506070809101112Expiry YearSelect Year20242025202620272028202920302031Private Health Details Fund NameSelect FundACA Health Benefits FundAHM Health InsuranceAustralian Unity health LimitedBUPA AustraliaCBHS Health FundCDH Benefits FundCUA Health LimitedDefence Health LimitedDoctors Health FundGMF HealthGMHBA LimitedGrand United Corporate healthHBF HealthHCFHealth Care Insurance LimitedHealth Insurance Fund of AustraliaHealth partnersLatrobe HealthMedibank PrivateMildura Health FundNavy HealthNIB Health FundPeoplecare Health FundPolice HealthQueensland Country Health FundRailway & Transport Health FundReserver Bank health SocietySt. Lukes HealthTeachers Health FundTransport HealthTUHWestfund limitedFund NumberSelect if applicableWorkcover3rd PartyDo you have a concession cardYesNoMedical Questionnaire How did you hear about usGP ReferredFriend or FamilySocial MediaMessenger / PaperSearch EngineOtherThe consultation fees charged by Dr Smith are based on the AMA Schedule of Fees, and are as follows: Initial Consult: $210 (Aged Pension $170). Review of Consult: $125 (Aged Pension $100). ACCOUNTS ARE PAYABLE IN FULL ON THE DAY OF CONSULTATION It is a term of the provision of these services that the patient shall be liable for all debt collection fees and charges, including but not limited to agent fees, solicitor costs and disbursements in the event that the collection is required. Please note that Medicare does not completely cover the cost of your consultation. Workcover and Third Party claims are managed separately. Other fees may be incurred for fractures and their management, casts, boots, injections, splints etc and for completion of medical forms for insurance, income protection and other such forms. I understand that payment of the account is my full responsibility. I consent to the release and communication of information from and to any other medical provider, for the purpose of my ongoing clinical management and for ongoing clinical research, audit and education (letters, Images, and Video). Clinical images may be used in a de-identified manner for marketing or education purposes. Dr. Smith is a Industry design Surgeon for some of the equipment utilised in Keyhole Bunion Surgery within Australia, and receives financial compensation for this. Dr. Smith is a founding surgeon involved in Eastwood Private Hospital. He has a financial interest in the facility and services available within the Hospital. This will not impact clinical decision making and recommendations for his patients. I agree with the above *YesNoSubmit
Please enable JavaScript in your browser to complete this form.Title *MrMrsMsMissMasterDrFirst Name *Last Name *Preferred NameDate of Birth *OccupationContact Details Home Phone Number Name of Last Work Phone NumberMobile Phone NumberEmailAddressAddress Line 1Address Line 2City--- Select state ---Please SelectSouth AustraliaWestern AustraliaVictoriaNew South WalesQueenslandTasmaniaAustralia Capital TerritoryNorthern TerritoryState / TerritoryPostalNext of Kin NameFirstLastPhoneRelationshipSelect an optionParentSonDaughterSpousePartnerSiblingRelativeFriendOtherReferring Doctor Name of Referring Doctor *Referring Doctor's Clinic *Is this your usual GP *YesNoPodiatrist Name and ClinicPhysiotherapist Name and ClinicHealthcare Details Medicare Number *Expiry MonthSelect Month010203040506070809101112Expiry YearSelect Year20242025202620272028202920302031Private Health Details Fund NameSelect FundACA Health Benefits FundAHM Health InsuranceAustralian Unity health LimitedBUPA AustraliaCBHS Health FundCDH Benefits FundCUA Health LimitedDefence Health LimitedDoctors Health FundGMF HealthGMHBA LimitedGrand United Corporate healthHBF HealthHCFHealth Care Insurance LimitedHealth Insurance Fund of AustraliaHealth partnersLatrobe HealthMedibank PrivateMildura Health FundNavy HealthNIB Health FundPeoplecare Health FundPolice HealthQueensland Country Health FundRailway & Transport Health FundReserver Bank health SocietySt. Lukes HealthTeachers Health FundTransport HealthTUHWestfund limitedFund NumberSelect if applicableWorkcover3rd PartyDo you have a concession cardYesNoMedical Questionnaire How did you hear about usGP ReferredFriend or FamilySocial MediaMessenger / PaperSearch EngineOtherThe consultation fees charged by Dr Smith are based on the AMA Schedule of Fees, and are as follows: Initial Consult: $210 (Aged Pension $170). Review of Consult: $125 (Aged Pension $100). ACCOUNTS ARE PAYABLE IN FULL ON THE DAY OF CONSULTATION It is a term of the provision of these services that the patient shall be liable for all debt collection fees and charges, including but not limited to agent fees, solicitor costs and disbursements in the event that the collection is required. Please note that Medicare does not completely cover the cost of your consultation. Workcover and Third Party claims are managed separately. Other fees may be incurred for fractures and their management, casts, boots, injections, splints etc and for completion of medical forms for insurance, income protection and other such forms. I understand that payment of the account is my full responsibility. I consent to the release and communication of information from and to any other medical provider, for the purpose of my ongoing clinical management and for ongoing clinical research, audit and education (letters, Images, and Video). Clinical images may be used in a de-identified manner for marketing or education purposes. Dr. Smith is a Industry design Surgeon for some of the equipment utilised in Keyhole Bunion Surgery within Australia, and receives financial compensation for this. Dr. Smith is a founding surgeon involved in Eastwood Private Hospital. He has a financial interest in the facility and services available within the Hospital. This will not impact clinical decision making and recommendations for his patients. I agree with the above *YesNoSubmit
Dr Mike Smith Eastwood Private Hospital Level 2, 204 Greenhill Road, Eastwood SA 5063 Ph: 08 7077 0156 | Fax: 08 7099 0171 Contact us
