Patient Registration Form

PATIENT DETAILS


PATIENT CONTACT DETAILS

PARTNER DETAILS

Your partner will need to sign this form before submitting.

PARTNER CONSENT

PARTNER INFORMATION RELEASE

I give consent for Dr Matthew Holland and staff to provide the medical information indicated to the person/s below:

PARTNER SIGNATURE

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REFERRING DOCTOR TO US

PATIENT MEDICARE

If you use Alias please write the Alias name & surname

PATIENT PRIVATE HEALTH INSURANCE

PATIENT DEFENCE / DVA

(mm/yyyy)

PATIENT MEDICAL RESULTS

Have you had any of the following tests?

PATIENT MEDICAL INFORMATION AND HISTORY

PATIENT CONSENT

PATIENT INFORMATION RELEASE

I give consent for Dr Matthew Holland and staff to provide the medical information indicated to the person/s below:


PATIENT FINANCIAL CONSENT

Initial Consultation Fee                                         $220                             Medicare item number 104 or 16401

Planning and Management Fee                           $2800                           Medicare item number 16590

Planning and managment pre-payment is due at 20 weeks gestation. Item number 16590 will be billed at 28 weeks gestation.

Antenatal reviews                                                Bulk Billed                  Medicare item number 16500

Ultasounds in rooms                                           Bulk Billed                  Medicare item number 55703-55725

Delivery Fee                                                           No Gap*                  Dr Holland will bill you fund directly for your delivery.

* A gap of $800 applies if you are covered by Latrobe or Frank.

Post Natal Consultation fee                                Bulk Billed                  Medicare item number 16407

The item number 16407 can only be billed once per pregnancy. If this item is billed by another doctor, your GP for example a fee of $100 will apply.

Subsequent Appointments                                 $100                  Medicare item number 105

Within a 12 month period under the one referral.

Theatre Fees                                                          No Gap*                  Dr Holland will bill you fund directly for your surgery.

Theatre Fees                                                          Self Funding                  

Dr Holland will provide an estimate for any surgery you choose to have, Dr Holland does not perform surgery in a public hospital.

PLEASE NOTE: The above fees do not include: ultrasounds, amniocentesis, CVS, genetic testing, pathology (including blood or uirne tests) or any imaging that may be required. 

It also does not include prvate hospital fees or charges from other specialists who become involved in your care i.e. anaesthetists, paeditricians and any other medical or allied health practitioners.

Dr Holland does not deliver or perfomr suregy at John Hunter Hospital.

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