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Secure Patient Portal – New Patient Questionnaire

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

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    Please enter a number from 0 to 100.
    Please enter a number from 0 to 100.
    Please enter a number from 0 to 100.

    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*
    Watching TV*
    Sitting, inactive in a public place (e.g. a theatre or a meeting)*
    As a passenger in a car for an hour without a break*
    Lying down to rest in the afternoon when circumstances permit*
    Sitting and talking to someone*
    Sitting quietly after a lunch without alcohol*
    In a car, while stopped for a few minutes in the traffic*
    Please select which classes of licence you hold:*
    Are you a member of any of the following occupational priority categories?*

    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*
    Permission to release patient 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.
    Clear Signature
    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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