New Patient Form – General Ortho

PATIENT DETAILS

NEXT OF KIN

PRIVATE HEALTH INSURANCE

LOCAL DOCTOR

PAYMENT TERMS

• CONSULTATIONS: Payment is expected at the time of consultation.
• NON-ATTENDANCE: If 48 hours is not given for cancellation of an appointment a $50 fee applies.
• In the event an overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs.
• Overdue accounts will be subject to interest at the rate of 25% per annum, calculated for the period the account is due.
• I have been advised of costs for my consultation including telehealth fees.

I have read the above Payment Terms and agree to abide by them.