ClinicALL website booking form

Appointment Booking

For existing bookings, please email info@clinicall.com.au.

Fee Schedule

Appointment type	Patient fee (upfront payment)	Gap/Out of pocket fee	Medicare Rebate*
New Appointment (Private - non Medicare card holders)	$55.00	n/a	n/a
New Appointment	$55.00	$19.30	$35.70

*Medicare rebates only available for consultations with NPs. GPs private billing only.

Preferred appointment date and time: *

Select a date for your

Would you like to book with a Nurse Practitioner(NP) or General Practitioner(GP)? *

Nurse Practitioner(NP) General Practitioner(GP)*

*Medicare rebates only available for consultations with NPs. GPs private billing only. By continuing I understand and accept this. *

Are you an existing or new patient? *

New patientExisting patient

Medicare

Do you have a Medicare card? *

YesNo

Do you use a different name in your Medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare first name

Medicare surname

Medicare card no. *

Medicare reference no. *The reference number is the number next to your name on your Medicare card.

Medicare expiry *

Request Type

I am after *

Short Telehealth Consultation - $55.00

You must have a Medicare or DVA card or IHI # to receive an escript.

Private Health Insurance: We cannot guarantee your payment will be claimable, we highly recommend confirming with your Private Health Insurer prior to making a booking.

How would you prefer to receive your Telehealth consultation through? *

Video call Phone call

Reason for consult:

Patient Details

First name *

Last name *

Preferred name

Date of birth *

Gender

MaleFemaleTransgenderPrefer not to say

Is English your first language?

YesNo

Ethnicity

ATSI *

AboriginalTorres Strait IslanderNone of the above

Parent/carer details

Parent/carer first name *

Parent/carer last name *

Parent/carer date of birth

Parent/care Medicare no. *

Parent/carer Medicare reference no. *

Patient Contact Details

Mobile phone *

Email *

Address *

Postcode *

City / Suburb

State

Health History

If you are currently taking medication, please list here:

Do you smoke?

YesNo

Do you have a history of blood pressure?

YesNo

Do you have any allergies?

YesNo

Please list your allergies:

Have you had a heart attack, stroke or other cardiovascular concerns recently?

YesNo

Do you have any of the following medical conditions?

Lung diseaseHeart diseaseMental healthNo

Are you pregnant, or likely to become pregnant?

YesNo

If so, are you breastfeeding?

YesNo

Consent

If eligible for Medicare, DVA or concessional billing do you give permission to bill? *

YesNo

If Bulk Billed, I assign my rights to the Healthcare professional who rendered the services. If eligible for a Mixed billed consultation a medicare rebate will be processed and deposited into your nominated bank account directly by Medicare. *

YesNo

We are committed to protecting your privacy and know it is important for you to understand how your information is handled.

In submitting the information contained in this form, you:

Consent to collection of personal information and Privacy Policy *

I confirm I have read and acknowledge the Billing Policy. *

Acknowledge that your health practitioner will collect such information (including any personal or sensitive information), for the purposes of providing you with health services or enabling any related communications. *

Payment

Please complete the following payment prior to submitting your form *

Pay

Signature

I confirm that above information I have provided is true, complete and accurate. *

Signature

Draw signature|Type signatureClear

Today's date

Save and Complete Later