Patient Registration

Please complete the online registration form before attending your first consultation with Dr Yong. This is recommended as this will speed up the registration process before the appointment.

Alternatively the form can also be completed when you arrive on the same day of consultation. It is recommended that you arrive 15 minutes prior to your appointment to allow registration of your details in the system.

Select

Name

First Name

Last Name

Subject

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Message

Date of Birth

YYYY

Phone - Mobile

Phone - Home

Occupation

Medicare Number

Medicare Reference Number

Medicare Expiry

Private Health Fund

Private Health Fund Number

CONCESSIONS

Veterans Affairs Card

Veterans Affairs Card Expiry

Pension Card Number

Pension Card Expiry

Exisiting health condition

Write "None" if no health conditions

Current medications

Write "None" if not on any medications

Known drug allergies

Write "None" if no known drug allergies

Pregnancy history - number of children & mode of delivery

Write "None" if no pregnancy history

Previous surgery

Write "None" if no previous surgery

YOUR GP

GP Name

First Name

Last Name

GP Contact Number

GP Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

NEXT OF KIN

Name

First Name

Last Name

Contact Number (mobile/phone)

Relationships to you

PRIVACY AND CONSENT

This practice is committed to ensuring a high-level of privacy and confidentiality. The information I ask you may be rather personal. However, not having it may restrict my capacity to provide you with the standard of medical care that you expect. Medical care requires full knowledge of patient health information by all members of a medical team. To ensure quality and continuity of patient care, patient’s health information may need to be shared with other healthcare providers including doctors and specialists who may become involved in treating you. This may occur through referral to other doctors and for medical tests. Some information may also be provided to Medicare and private health funds if relevant, for billing and medical rebate purposes. Disclosure to others for medical defence purposes may also be required.

Should my health information be required for purposes other than those listed above, I understand that my further consent will be required.

I acknowledge that I have read and understand the above Privacy Consent Form.

FEE STRUCTURE AND FINANCIAL CONSENT

Your initial consultation incurs a fee of $280 with a rebate from Medicare of approximately $81.30. (Fees are reviewed every November in accordance with Medicare Australia). Any subsequent consultations (within the 12 month period of your initial referral) will be $140 with a rebate from Medicare of $40.85. It is your responsibility to ensure your referral is current prior to all consultations. Payment of your account is requested on the day of your consultation. Payment can be made by Cash, Visa, Mastercard or Eftpos. If you are Veteran Affairs Gold cardholder, your consultation account will be sent directly to Veteran Affairs. However, if you require a pessary please be aware that Veteran Affairs does not cover this cost and payment will be required on the day of your consultation.

If you are privately insured, accounts on urodynamics study and cystoscopy will be sent directly to your Health Fund. As you are admitted as a day patient at Frances Perry House or Epworth Freemasons, there may be out of pocket for any excess applied by your Health fund. If you do not have private insurance, a quote for these tests will be provided to you prior to booking these procedures.

A cancellation fee will apply for any procedures that are either cancelled or altered by you after you have received your booking confirmation. If you require any prosthesis (such as a pessary) depending on the type of pessary the fees range from $100 which is not claimable from Medicare or your Health fund. If you do need to undergo surgery you will be sent an itemised quote prior to making a definitive booking. No surgery date will be made prior to your appointment with Dr Yong and the quote issued.

I accept liability for any services or charges that are incurred as part of my health care and treatment provided by Dr Yong. Prior to undergoing any surgical procedure an itemised estimate of costs will be provided. I understand that any change in my surgery provided by Dr Yong may result in a variation in the original estimation of costs.

I have read and understand the above Financial Consent Form and acknowledge and agree to my financial obligations to Dr Yong in undergoing my treatment.

I also understand that any surgical accounts are to be finalised within 14 days of surgery.

Where did you hear about us

If you answers 'Other' please describe below