Emergency Contact Details / Next of Kin
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Third Party Insurance Details (Workcover/TAC)
Please note: In an effort to keep costs down for our patients, the practice policy is for payment on the day of consultation. You will have received advice from reception upon booking your appointment or procedure of the associated costs. These costs may vary due to extra testing or the complexity of your condition.
Failure to attend your appointment may incur a cancellation fee.
I acknowledge that my personal information may have to be disclosed to, or collected for, Government and Health Fund statistics or to other treating health professionals so that my health care is not compromised. It will, however, be disclosed to other organisations where required by law or if necessary for debt collection purposes.
,give consent to Windsor Avenue Day Surgery/ Mornington Endoscopy/ Rosebud Endoscopy to receive and send my health/personal details by fax. I have read and understand the above.
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