Practice letterhead
Before your surgery, we want you to understand the costs involved and what you may need to pay yourself. Please read this form together with your fee quote, ask us about anything that is unclear, and sign below.
Your details
Patient
Procedure
Surgeon
Hospital
Proposed date
Fee quote
Summary of fees from our rooms
Total fee
Est. Medicare + fund rebate
Est. out of pocket
Please tick each statement to confirm
I have received a written quote for my surgeon’s and assistant’s fees. *
I understand the estimated out-of-pocket amount I will need to pay, and when it is due. *
I understand the anaesthetist and hospital will bill me separately, and that other services (such as pathology, radiology or prostheses) may also be billed separately. *
I understand that Medicare and health fund rebates are estimates, and that I should confirm my cover with my health fund. *
I understand that fees may change if my procedure changes, and that the practice will discuss any changes with me. *
I have had the opportunity to ask questions about the fees, and my questions have been answered. *
Consent
Patient name *
Signature *
.webp?width=532&height=250&name=MR-Logo-vector-v011%20(1).webp){kind=logo}
