Becoming a patientNew patient formThank you for filling out our online new patient form. Step 1 of 3 33% New patient formName* First name Surname Preferred name* Preferred name Title Date of birth* Day Month Year Occupation Residential address Street Address City State / Province / Region ZIP / Postal Code Your email* Mobile phone numberHome phone numberWork phone numberMedicare* No Yes Medicare number Medicare ref Medicare expiryPlease enter month / year Dept of veteran affairs Card colorSelectWhiteGoldDo you identify yourself as*SelectAboriginalTorres Strait IslanderBothNeitherNominated GP detailsGP name Practice name GP phoneGP referralUpload your GP referral here if you want a Medicare rebateAccepted file types: pdf, jpg, png, Max. file size: 5 MB.Private insurance detailsHealth fund Member number Workers compensation / ICWA detailsApplicable? No Yes Insurer Claim number Employer PhoneInjury Date of injury Day Month Year Emergency contact detailsName First Last PhoneRelationship How did you hear about our clinic? Recommendation by friend / family Returning patient Google Social media Other If other, please share how Privacy and financial consent form Please find below a table of fees for the consultations available at the clinic: CONSULT TYPE Initial surgeon consult Subsequent consult Nurse consult Post-operative consult FEE $300.00 $150.00 $65.00 First post-operative consult included in surgical fee, $150.00 thereafter ITEM NUMBER 104 105 N/A 105 REBATE (APPROX.) $76.80 $38.60 N/A $38.60 The following conditions apply to payments for consultations at Dr Rawlins clinics: A valid REFERRAL must be provided to Dr Rawlins in order to be eligible for a rebate. It is at the discretion of Medicare and your health fund if a rebate will be provided. Medicare may change rebate amounts without notice. Regular post-operative care will be provided for a duration of 4-8 weeks following a surgical procedure. As part of the surgical fees this includes 2 x nurse post operative appointments and 1 post-operative consult with Dr Rawlins. Further appointments will incur a fee as outlined above. Payment is due on the day of your appointment. SURGICAL PROCEDURES REQUIRE FULL PAYMENT TWO WEEKS PRIOR TO THE DATE OF PROCEDURE Dr Jeremy Rawlins bills for reconstructive/ non cosmetic surgical procedures according to rates set by AMA (Australian Medical Association). Depending on your level of cover, your private health fund may cover part of the surgical fee. However, the surgical fee is likely to include a ‘gap’ between a range from $300 to $20,000 depending on the complexity of the surgery. Procedures performed in the clinic as an outpatient will incur a facility fee ranging between $350 and $1200. This fee is NOT claimable from Medicare or your private health fund. A quote will be drawn up after your consultation with Mr Rawlins and can be discussed with the Practice Secretary. These charges are payable prior to a tentative procedure date to confirm your booking. In special circumstances, an arrangement can be made where an account can be paid within 14 days from the date of invoice. By signing this consent form, you understand that you will accept liability for payments of all accounts, including the possibility that health funds/ insurer rejects any claims or reduce their payment benefits.Patient signature to confirm financial consent and acceptance of liability for payment of all accounts.*This signature confirms financial consent and acceptance of liability for payment of all accounts.Date* Day Month Year Consent to photography Clinical photographs can be valuable in tracking your progress and recovery, in evaluating the effects of your treatment, for communication with other health care professionals who are involved in your treatment, and for further education and clinical researchPatient declaration* First name Surname I consent for clinical photographs to be taken for the purposes of my ongoing treatment with Dr Jeremy Rawlins. I agree that the images may be (please tick according to your preference) Note, the images used will have no identifying information such as name and faces will not be included in the images unless this is the site of the medical problemUsed in my medical record* No Yes Used for teaching of medical, nursing, or allied healthcare workers and staff in Australia and abroad* No Yes Published in medical journals, textbooks, or other forms of medical publication* No Yes Used for the purposes of patient education undergoing similar medical procedures.* No Yes I acknowledge that* I have read the above information and have received an explanation about what clinic photography will be taken and why. I am not obliged to agree to clinical photography being taken as part of my treatment but in some circumstances my failure to do so may impact on the quality of treatment that can be provided to me. I understand that my photographs will not be used for any purpose other than set out above without my consent. I understand that I may withdraw my consent at any time. I understand that if I withdraw my consent there will be no new use of my clinical photography by Jeremy Rawlins Plastic Surgery but that images cannot be removed from existing publications and may remain within the public domain. ConfirmPatient / guardian signature photography consent*Date* Day Month Year To send the form, please answer this question to help prevent spam*A panda is black and ..... CommentsThis field is for validation purposes and should be left unchanged.