Patient Registration and Consent Form

PATIENT DETAILS

PATIENT CONTACT DETAILS

We may correspond with you by SMS, regarding appointment details or health information. SMS may not be secure. If you do not wish to receive SMS from us, please let us know.
We may correspond with you by email, regarding appointment details or health information. Email may not be secure. If you do not wish to receive emails from us, do not include your email.

EMERGENCY CONTACT DETAILS

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MEDICARE

PENSION / HCC/DVA Card

(dd/mm/yyyy)

Medical Information

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Informed Financial Consent

The fees are determined at the discretion of your dermatologist. The usual fees for our most common services are:


Medicare item number

Private fee

Pensioner fee

Medicare rebate*

Initial consultation

104

$250

$195

$78.05

Follow up

105

$165

$120

$39.25

Biopsy

30071

$120

$100

$45.80

Excisional biopsy**

31366

$250 or more

$164.90 or more

$83.70 or more

Steroid injections

30207

$110

$90

$39.10

Cryotherapy

30192

$100

$80

$34.70

Surgical removal of a lesion

Depends on the location, diagnosis and size of the surgery. Please discuss this with reception and your Dermatologist.

* If you are registered for the extended Medicare safety net, additional rebates may apply if you have reached the annual threshold.

** Varies according to lesion size and body part.

The above fees may change without notice.

The medicare rebate will be processed on the day and refunded into your account. Your dermatologist always balances the need for a procedure against risks, discomfort and costs of that procedure, and of course, only recommends a procedure if it is likely to be beneficial in their judgment. When you confirm your booking you are accepting these prices.

Additional fees you may incur:

Additional fees will be incurred for any service (treatment or surgical procedure) performed during your consultation. You may ask your dermatologist for a financial estimate before the treatment or procedure is performed.

Fees charged by this practice do not include the cost of external service providers, such as pharmacists, pathologists or radiologists. You may be invoiced separately by these external service providers;  Medicare and Health fund rebates may apply.

Notes:

  • We are not a bulk-billing practice. Fees are are subject to change without notice.

  • If your dermatologist decides to bulk-bill your in-person or telehealth consultation, by signing this financial consent, you consent to North Coast Dermatology receiving the medicare rebate. 

  • Your dermatologist may provide a fee reduction if you hold a current Pensioner Concession Card. Please present your card to our reception staff.

Account payment:

  • Your account needs to be settled at each consultation. We accept EFTPOS (Mastercard and Visa), cash, cheque.

  • For some procedures, the item numbers and fees are not determined until after the pathology report has been received. In these cases, you will be invoiced one-two weeks after the procedure.

  • If you have an outstanding balance on your account, then you may not be given another appointment until the account is settled. You may be liable for additional costs involved in the debt recovery process.


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Privacy consent


Patient consent for the collection, use and disclosure of health information 

 

This consent form is a requirement for admission and treatment at North Coast Dermatology.  We request you to sign our privacy consent in order to provide you with the best possible healthcare.  If you choose not to consent or not to consent to certain items, your treatment may be affected. Our Privacy Policy is available at reception. Please read the Privacy Policy for an explanation of how and why your information will be used.  

We routinely take medical photographs of your skin to assist with your diagnosis. These form part of your confidential medical record. Please inform your doctor if you do not wish to be photographed.

We may contact you via SMS. Please advise us if you would prefer not to be contacted by this means. 


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