Personal Information

Are you
Who is responsible for your account?

Result of TAC / Workcover

Please note: Workcover and TAC patients require written approval that claims made from our practitioners will be covered

Emergency Contact Information

Medical Practitioner Information

Referral information: Referrals provided by a General Practitioner last for a period of 12 months unless your Doctor has specified "ongoing" or "indefinite" referral. After 12 months it is essential for you to provide a new referral from your General Practitioner to meet Medicare requirements. If you have been referred by a Specialist Physician or through a Public Hospital your referral will only last for a period of 3 months, we recommend obtaining a referral from your General Practitioner

Medical Release

  • All fees are due and payable at the time of your consultation unless otherwise arranged. Where prior arrangement has been made for later payment a $15 administration fee will apply and ALL invoices MUST BE PAID within 7 days
  • If your insurer or the organisation / individual listed as responsible for your account deny liability, you will be responsible for payment for services rendered
  • I provide consent for Nepean Cardiology to obtain any relevant test results and correspondence relating to my medical history.
  • I provide consent for results and correspondence to be sent to my referring and usual doctors as well as other medical professionals involved in my care when requested.
  • I provide consent for messages to be left with immediate family members (eg. for Appointment Confirmation)
  • I understand that Consultation Fees are due for payment on the day of Consultation (gap payments are not accepted)
Do you accept the Medical Release?