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Secure Patient Portal – New Patient Questionnaire

"*" indicates required fields

Name*

First Last

DOB*

Gender*

Email*

Mobile phone number*

Which location to you prefer?*

Is there a specific physician you'd like to see?*

Are you Medicare or DVA eligible?*

Medicare Card Number*

Please include the individual reference number, which is the number before the name.

DVA Number*

DVA card type*

Eg gold, white

Are you privately insured?*

Private Health Insurer*

Private Health Insurance membership number*

Level of cover*

Please select what type of disorder you are coming to see us about:*

Informed Financial Consent

The following fee will be payable on the day of the consultation: $650.00. This includes a complex breathing test (30 minutes) and a consultation with the specialist of up to 30 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $273.10. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

The following fee will be payable on the day of the consultation: $656.00. This includes a complex breathing test (30 minutes) and a consultation with the specialist of up to 30 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $273.10. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

The following fee will be payable on the day of the consultation: $624.75. This includes a complex breathing test (30 minutes) and a consultation with the specialist of up to 30 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $273.10. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

The following fee will be payable on the day of the consultation: $594.75. This includes a complex breathing test (30 minutes) and a consultation with the specialist of up to 30 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $271.10. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

The following fee will be payable on the day of the consultation: $744.75. This includes a complex breathing test (30 minutes) and a consultation with the specialist of up to 30 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $380.40. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

The following fee will be payable on the day of the consultation: $477.65. This includes a complex breathing test (30 minutes) and a consultation with the specialist of up to 30 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $258.10. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

As you have indicated that there is more than one problem to address, the following quote is based on a long appointment. If on the day, the problem is determined by the specialist to be less complex, a lower fee may be charged.

If you are being assessed for one issue, please reselect either respiratory OR sleep options in the above drop down.

The following fee will be payable on the day of the consultation: $865.00. This includes a complex breathing test (30 minutes) and a consultation with the specialist of 45 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $359.60. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

As you have indicated that there is more than one problem to address, the following quote is based on a long appointment. If on the day, the problem is determined by the specialist to be less complex, a lower fee may be charged.

If you are being assessed for one issue, please reselect either respiratory OR sleep options in the above drop down.

The following fee will be payable on the day of the consultation: $737.65. This includes a complex breathing test (30 minutes) and a consultation with the specialist of 45 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $359.60. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

As you have indicated that there is more than one problem to address, the following quote is based on a long appointment. If on the day, the problem is determined by the specialist to be less complex, a lower fee may be charged.

If you are being assessed for one issue, please reselect either respiratory OR sleep options in the above drop down.

The following fee will be payable on the day of the consultation: $737.65. This includes a complex breathing test (30 minutes) and a consultation with the specialist of 45 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $359.60. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

As you have indicated that there is more than one problem to address, the following quote is based on a long appointment. If on the day, the problem is determined by the specialist to be less complex, a lower fee may be charged.

If you are being assessed for one issue, please reselect either respiratory OR sleep options in the above drop down.

The following fee will be payable on the day of the consultation: $737.65. This includes a complex breathing test (30 minutes) and a consultation with the specialist of 45 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $359.60. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

As you have indicated that there is more than one problem to address, the following quote is based on a long appointment. If on the day, the problem is determined by the specialist to be less complex, a lower fee may be charged.

If you are being assessed for one issue, please reselect either respiratory OR sleep options in the above drop down.

The following fee will be payable on the day of the consultation: $737.65. This includes a complex breathing test (30 minutes) and a consultation with the specialist of 45 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $359.60. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Informed Financial Consent

As you have indicated that there is more than one problem to address, the following quote is based on a long appointment. If on the day, the problem is determined by the specialist to be less complex, a lower fee may be charged.

If you are being assessed for one issue, please reselect either respiratory OR sleep options in the above drop down.

The following fee will be payable on the day of the consultation: $737.65. This includes a complex breathing test (30 minutes) and a consultation with the specialist of 45 minutes, including writing a detailed report back to your referring doctor.

If you are Medicare eligible, we anticipate a rebate of at least $359.60. Medicare will usually deposit this back into your bank account within 24 hours.

We are a cashless practice. No transaction fees apply to EFTPOS (savings/cheque) transactions. A surcharge of 0.9% applies to credit/debit card and Tap & Pay transactions.

Who is your referring doctor?*

Where does your referring doctor practice?*

Enter suburb or hospital name.

Who is your usual GP?

Where does your GP practice?

Who is your next of kin/emergency contact and what is your relationship?*

What is your next of kin's phone number?*

Are there any other doctors who you would like us to send reports to?*

Please attach your referral (if not already sent) and any other relevant documents (note that you can use your smartphone camera to capture the document).

Drop files here or

Accepted file types: pdf, jpg, png, gif, Max. file size: 20 MB, Max. files: 5.

Maximum 5 documents

Please list any medical conditions which you are CURRENTLY being treated or monitored for:*

Please list your current medications INCLUDING dosage and frequency:*

Do you have any allergies to medication?*

Please list your allergies, what happened and when.*

Please list any INACTIVE medical problems or procedures which you've had in the past.*

Have you ever been a smoker?*

Approximately, what is the total number of years that you have smoked for?

Please enter a number from 0 to 100.

Approximately, what was the total number of years that you smoked for?

Please enter a number from 0 to 100.

Please estimate the average number of cigarettes that you have smoked, per day, over the years that you have smoked

Please enter a number from 0 to 100.

Please estimate the average number of cigarettes that you smoked, per day, over the years that you smoked.

Please enter a number from 0 to 100.

Calculated smoking pack years

Calculated smoking pack years

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?

This refers to your usual way of life in recent times.

Even if you haven’t done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

It is important that you answer each question as best you can.

Sitting and reading*

0

1

2

3

Watching TV*

0

1

2

3

Sitting, inactive in a public place (e.g. a theatre or a meeting)*

0

1

2

3

As a passenger in a car for an hour without a break*

0

1

2

3

Lying down to rest in the afternoon when circumstances permit*

0

1

2

3

Sitting and talking to someone*

0

1

2

3

Sitting quietly after a lunch without alcohol*

0

1

2

3

In a car, while stopped for a few minutes in the traffic*

0

1

2

3

Your ESS score:

Do you hold a motor vehicle licence?*

Please select which classes of licence you hold:*

C

MR

HR

HC

Dangerous Goods

UD

R

Taxi / Rideshare / Passenger carrying

Are you a member of any of the following occupational priority categories?*

Railway - Cat 1

Railway - Cat 2

CASA Commercial

CASA Recreational

Commercial driver

None of the above

How did you find us?*

Personal & Health Information Consent

We respect your rights to privacy and take our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988 (Cth). Our Privacy Policy can be obtained from:

https://www.respirologist.com.au/privacy
Reception
By calling (07) 3123 5350

We require your consent to collect personal information and health information about you. Please read this information carefully, and acknowledge your acceptance where indicated below.

Respirologist Pty Ltd collects information from you for the primary purpose of providing you healthcare services. We require you to provide us with your personal and health information including your full medical history so that we may provide our services to you. We will also use the information you provide in the following ways:

appropriately manage our practice, such as conducting audits and undertaking accreditation processes, manage billings and training staff;
effectively communicate with third parties, including the Medicare Australia, private health insurers, government departments and other practitioners involved in your healthcare;
for research purposes where we will seek your consent

Acknowledgement*

I have read the information above and understand why my information is collected and how it is used. I acknowledge that I am not obliged to provide any information requested of me, but that failure to do so might compromise the quality of care provided to me.

I acknowledge that the fees for the professional services are payable on the day of the consultation.

I have read the cancellation policy and I am aware that cancellation within 72 hours or failure to attend without extenuating circumstances will result in a cancellation fee being charged to me that I am liable to pay.

I consent to receive communication from the practice and associated medical specialists via the email address nominated above and by SMS via the mobile telephone number listed above.

Permission to release patient information*

Yes, I authorize the release of all medical information relating to me and my care to Respirologist from other doctors, health practitioners, hospitals and medical practices.

No, I do not authorize the release of my medical information from other practitioners and understand that it may not be possible to properly assess my condition without this information.

I authorize the release of all medical information relating to me and my care to Respirologist from other doctors, health practitioners, hospitals and medical practices.

Signature

Name and date

If you are unable to submit the form, it will be because you have missed a mandatory question. Please ensure every question with a red asterisk has been answered (type n/a into boxes if there is no relevant information to provide).

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