Personal Information

Please note: if the insurer or persons listed above deny liability you will be responsible for payment of all accounts

Parent 1:

Parent 2:

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)