Paediatrics Telehealth e-Form (Initial)

Initial (telehealth) Consultation

Please fill out the following Telehealth e-Form with your details and click the submit button at the end. We will contact you after we receive your completed form.

(Please fill out all the fields) (Form: paedinitial)

Child's (Patient) Details

Date of Birth

Address


Parent Details

Date of Birth

Medicare Card Details


Clarification about telehealth services (consent required)

We want to make sure you are aware that:

  • A video/phone consultation will not be exactly the same, and may not be as complete, as a face-to-face service.
  • There could be some technical problems that affect the quality of a video visit.

Please confirm you understand the limitations of a health service provided online and are happy to proceed.

  • If the teleconference does not achieve everything that is needed, you will be given a choice about what to do next. This could include a follow up face-to-face visit, or a second video/phone visit.
  • You can change your mind and stop using teleconference consultations at any time.
  • This will not make any difference to your right to ask for and receive health care.
  • Medicare requirement to consent for telehealth services provided from a specialist.
  • Please upload the referral you have from your GP (and/or any other supportive/related document you might have and would be helpful) as it is clinically important for our doctors to have the information they need and for you to be able to claim the medicare rebate.
  • The full private fees for tele-health including Medicare Rebate can vary from $315 (Item Number 91824-91834) to $415 (Item Number 92422-92431) dependent on consult type. Some consultations may be eligible for bulk-billing subject to clinician’s discretion.

Debit account & credit card payment authorization

By completing this part you hereby authorize Brighton Health Clinic for Kids to debit your bank account or credit card shared below, for each session on the day of consultation. This is permission for the amount to be charged as per our fees described above. Any additional costs for extended sessions or further assessments cannot be charged without confirmation from the client. This authorization does not provide authorization for any additional unrelated debits or credits to your account.

We take automatic payment on the day of consultation and a receipt is issued via email. All credit card payments will incur a surcharge of 1.010% during processing. Kindly note that declined cards may result in an additional processing fee as it will go through an additional process when the attempted card is charged again. You authorize the above named business to charge your bank account or credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the services described above, for the session cost only. You certify and confirm that you are an authorized user of this bank account or credit card.

I consent to all the above: Yes, No

Payment Details

Credit Card Type
Card Number:

Please upload referral or related documents