FINANCIAL POLICY
All fees are your responsibility, even if claiming through an insurance company. Please give 24 hours notice if cancelling an appointment, otherwise a fee will be charged. We are covered by all major
Health Insurance Companies including PPP and BUPA
Signed:_________________________________________________ Date:______________________________
_______________________________________________________________________________________________________
CONSENT TO EXAMINATION
I consent to an appropriate physical examination.
Signed:_________________________________________________ Date:______________________________
If you are under 16 years of age, this consent should be signed by a parent or legal guardian.
Signed:___________________________________(Parent/Guardian) Date:_____________________________
_______________________________________________________________________________________________________
CONSENT TO TREATMENT
I have been given a Report of Findings regarding my condition. I have been advised of, and understood, the possible risks and benefits of treatment and had all my questions answered to my satisfaction. I consent to treatment as outlined to me.
Signed:_________________________________________________ Date:______________________________
If you are under 16 years of age, this consent should be signed by a parent or legal guardian.
Signed:___________________________________(Parent/Guardian) Date:_____________________________
_______________________________________________________________________________________________________
FEMALE PATIENTS ONLY: no. of children [ ] Is there any possibility, however small, that you may be pregnant? Y/N
Signed:_________________________________________________ Date:______________________________
