Welcome to Adelaide Plastic Surgery

To help us prepare for your appointment, we ask that you complete this form and attach your doctor’s referral letter (if applicable). If you are unable to attach your referral here, or your referring practitioner is sending the referral direct to us, you can send it separately by fax (08 8213 1811) or email: reception@apsa.com.au.

On the day of your appointment, please bring:

Relevant test results and scans
Your Medicare, Health Fund and Age Pension cards (if applicable)
Any other important information

In the next steps, you will find information regarding our clinic fees. Full payment is required on the day of your appointment. We accept EFTPOS, credit card, or cash. If you are unable to attend, please advise us as soon as possible. Cancellations within 24 hours (including non-attendance) may attract a cancellation fee.

We look forward to welcoming you to our Practice.

Patient Registration Form

PATIENT INFORMATION

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

MaleFemaleNon-BinaryPrefer not to say

ATSI

AboriginalTorres Strait IslanderNone of the Above

English is a Second Language

YesNo

Ethnicity

Occupation *

PATIENT CONTACT DETAILS

Main Phone Number *

Alternative Phone Number

Email *

Patient Residential Address *

Street address *

City *

State *

Postcode *

I agree to receive SMS and email communications regarding my appointment. *

I agree to receive SMS and email communications regarding marketing. *

EMERGENCY CONTACT / NEXT OF KIN (NOK)

Emergency Contact First & Last Name *

Emergency Contact Phone Number *

Emergency Contact Email Address

MEDICARE

Do you have a Medicare Card? *

YesNo

Medicare First Name *

Medicare Last Name *

**Please complete as written on your Medicare card.

Medicare Card No. *

Expiry *

PRIVATE HEALTH INSURANCE

Do you have private health insurance? *

YesNo

Do you have? *

Hospital & Extras CoverHospital Cover OnlyExtra's Cover Only

Provider *

Membership No. *

Expiry *

In order to claim through Private Health Insurance and Medicare, your planned procedure must fit Medicare item number criteria to cover the theatre fee and any hospital stay. Even when there is a Medicare item number, you may incur expenses that may not be fully covered by Medicare or your health fund. These costs may include a ‘gap’ between the surgical fee and what is covered by Medicare, anaesthetic and surgical assistant fees, implants and prostheses, non-rebatable single-use surgical equipment, radiology and pathology tests, scar management treatments, allied health care and clinic visits beyond usual after-care.

PENSION / HEALTH CONCESSION / DVA

Do you have an aged pension card, healthcare card or a DVA card? *

YesNo

Card Type *

HCCPensionDVA

Card No. *

Expiry *(mm/yyyy)

WORKCOVER

Is this a Workcover / Third Party Claim? *

YesNo

Date of injury *

Employer Name *

Contact Person *

Employer Contact Number *

Employer email address *

Has your claim been lodged and accepted *

YesNo

If yes, what is your claim number? *

Insurance Company (eg: EML/Gallagher Bassett) *

Name of case manager *

Case manager's phone number *

Case manager's email address *

Please note: For patients lodging a claim through Workcover or another third party entity, it is essential for us to provide them (upon written request) information regarding your injury and planned treatment. This is particularly essential if you require surgical intervention as prior approval is required. If your claim has not been accepted as yet, or you have not lodged a claim, you are required to pay all costs yourself on the day and claim back from Workcover. If your claim is later rejected, you will be liable for all medical costs incurred to date.

REFERRING PRACTITIONER

Name of Referring Practitioner *

Referring Practitioner Contact Phone Number *

Referring Practitioner Address *

Street address *

City *

State *

Postcode *

Upload your referral letter here

Browse

Referral Required - Please note that an appointment can only be offered once we have received a valid referral letter.

USUAL GP DETAILS

Is your referring practitioner different to your usual GP *

YesNo

GP’s Name *

GP Contact Phone Number *

GP Address *

Street address *

City *

State *

Postcode *

MEDICAL CONDITIONS

Please list your medications

Please list allergies / sensitivities

Do you live with Diabetes *

YesNo

If you live with Diabetes, please indicate *

Type 1Type 2

CONSENT - USE OF CLINICAL PHOTOGRAPHS / VIDEOS

All clinical images are stored securely and may only be accessed by authorised clinical staff. I give permission for Adelaide Plastic Surgery to use my clinical images for the following purposes (please tick as applicable): *

Medical record onlyEducation (e.g. presentations, training, teaching)To be shown to prospective patients during consultation with one of our Specialist Plastic Surgeons

YOUR PRIVACY AND MEDICAL RECORDS

1. In accordance with section 6(1) of the Privacy Act 1988 (Cth) (Privacy Act), all information collected in this practice is treated as ‘sensitive information’. To protect your privacy, APSA Services Pty Ltd (ACN 085 393 700) trading as Adelaide Plastic Surgery Associates (“APSA”) operates in accordance with the Privacy Act and its Privacy Policy.

2. A copy of our Privacy Policy is available free of charge from reception or on our website at apsa.com.au.

3. Your Surgeon and/or nurse uses the information you provide to manage your health care which may include using the information for the following purposes (including instructing APSA to use the information for the following purposes on your surgeon’s behalf):

(a) collect, record, and store my personal and health information that will form part of an individual computerised medical record including through the use of transcription software;

(b) issue reminders for specific health checks I may require, if any, as part of my consultation with my surgeon and/or nurse;

(c) provide me with health information updates, general medical updates and provide my personal and health information to the relevant state and/or national recall reminder registers; and

(d) use my personal and health information to undertake administrative tasks involved in the running of APSA, and for my surgeon, billing tasks which includes compliance with Medicare, Health Insurance Commission, and other relevant Government agency requirements.

4. You can assist in maintaining the accuracy of your information by advising your surgeon or reception of changes in your contact details.

5. Selected information may be disclosed to various other health care providers involved in supporting your health care management (e.g. pathology and imaging providers, hospitals, or other specialists). You hereby acknowledge and consent to the disclosure and/or use of your personal health information by APSA, your surgeon and persons directly or indirectly involved in your personal health care or medical treatment for that purpose, including:

(a) sending specimens obtained from me to the necessary pathology provider for analysis. As a result, I understand that I may incur an out-of-pocket expense, by which a separate invoice will be issued by the relevant pathology provider. I understand that I will be liable for all expenses incurred;

(b) disclosing my personal and health information to the relevant medical and allied health service providers involved in my care;

(c) disclosing de-identified personal and health information for research and quality assurance purposes undertaken by my surgeon to improve the quality of both individual and community health care needs and practice management. APSA will inform me when such activities are being conducted and give me the opportunity to ‘opt-out’ of any involvement at any time; and

(d) using my personal and health information by my surgeon and other authorised individuals involved in my medical care and treatment, both directly and indirectly.

6. If you have any questions regarding the management of your personal health information or need to arrange access to your records, please ask reception or your surgeon, as appropriate.

7. I am not obliged to provide information requested of me, but that my failure to do so may compromise the quality of care provided to me by my surgeon.

8. I understand my right to access both my personal and health information held by APSA, except in circumstances where access is legitimately withheld. If my personal and health information is to be used for any other purpose, other than what is set above, my further consent will be obtained.

9. I understand it is my responsibility to inform APSA as soon as possible of any changes to my personal and health information. If any information held about me is inaccurate, I may request to have this altered accordingly.

10. Use of Artificial Intelligence (AI) Transcription Services. APSA and your surgeon may use Artificial Intelligence (AI)–assisted transcription software to support the creation of accurate medical records and letters following your consultation. This technology allows your surgeon to spend more time focusing on your care while ensuring that accurate documentation is maintained.

AI transcription may occur in real time during your consultation or via short-term secure audio processing.
Data is processed on Australian servers, handled in accordance with Australian Privacy Principles, and deleted after a short period.
Information is never sent overseas.
All transcriptions are reviewed and approved by your surgeon before being included in your permanent medical record.

You hereby acknowledge and consent to the disclosure and/or use of your personal health information by APSA and persons directly or indirectly involved in your personal health care or medical treatment for the purposes set out above.

If you have any questions regarding the management of your personal health information or need to arrange access your records, please ask reception or your surgeon, as appropriate. If you do not wish for this to occur, please advise reception.

PRIVACY COLLECTION STATEMENT

APSA collects your personal information for purposes related to (or in the case of sensitive information, directly related to) our functions or activities, including facilitating the delivery of health services to you from your surgeon or our nurses, informing you of services which may be relevant to you and to communicate with you on behalf of your Plastic Surgeon. We may not be able to facilitate the delivery of health services from your Plastic Surgeon to you if you do not provide this information. Your personal information may be disclosed to our related bodies corporate, surgeons, and third-party services providers. Your personal information is kept private and secure, as required by federal and state privacy laws. Please refer to our Privacy Policy for full details of how we handle your personal information, including how you may access and seek correction of your personal information, complain about a privacy breach, and how we will deal with that complaint.

FEE STRUCTURE

Specialist Plastic and Reconstructive Surgeons

Dr Timothy Edwards Dr Peter Sylaidis Dr Nicholas Marshall Dr Anthony Porter

Dr Jenny Roy Dr Amy Jeeves Dr Jia Miin Yip Dr Douglas Copson

Medical Consultations - A valid referral is required to claim your rebate from Medicare

Standard consultation	$200
Long consultation	$300
Follow up consultation	$110
Age Pension initial consultation	$120
Age Pensioner follow up consultation	$80

Cosmetic Consultations - A valid referral is required

Initial consultation (Medicare rebate not applicable)	$300
Follow up consultation (Medicare rebate not applicable)	$120

All fees are payable in full on the day of your consultation
Additional fees will apply if you need an appointment with the Hand Therapist
If Surgical treatment is required, you will be given an Informed Financial Consent outlining your expected out-of-pocket “gap” after Medicare and Health Fund rebates
Where applicable, all surgical fees include 6 weeks of post-operative consultations. Any follow up after the 6 week post-operative period, will be billed as outlined above

General Surgeon and Surgical Oncologist

A/Prof Beverley Fosh

Initial consultation	$300
Follow up consultation	$120

A valid referral is required to claim your rebate from Medicare
All fees are payable in full on the day of your consultation. We accept credit cards, EFTPOS or cash/ A 1.2% surcharge will apply for all AMEX transactions. No cheques.
We do not accept Health Care Cards
If Surgical treatment is required, you will be given an Informed Financial Consent outlining your expected out-of-pocket “gap” after Medicare and Health Fund rebates
Where applicable, all surgical fees include 6 weeks of post-operative consultations. Any follow up after the 6 week post-operative period, will be billed as outlined above

Hand Therapist

Initial Consultation - Short	$135
Review Appointment - Short	$95
Initial Consultation - Long	$165
Review Appointment - Long	$125

You can claim from your Private Health Fund if you have “Extras” cover which includes “Occupational Therapy”

Nurse Consultations

Initial Consultations with our nurses are Complimentary.

Consultations for tattoo removal and laser rejuvenation will be quoted during your initial consultation.

Dermal Consultations

Consultations with our Dermal Nurses are Complimentary. Treatment costs will be discussed with you prior to any treatment taking place.

Cancellation and No-Show Policy

We understand that situations arise in which you need to cancel your appointment, however, we do require at least 24 hours' notice (any change to a Monday appointment needs to be confirmed by 12pm the Friday prior). This will allow us to schedule another patient and keep our wait lists to a minimum. If insufficient notice is given, or you do not attend your appointment, a cancellation fee may apply.

SIGNATURE

I confirm that I have read and understood the information provided in this form and that the information I have given is true, complete and accurate. *

My appointment at Adelaide Plastic Surgery is with: *

Patient/ Guardian Signature *

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Today's Date *

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