Name *

First Name

Last Name

Private Health Insurance *

Yes

No

DVA card colour

Gold

White

Pensioner concession (Red & Blue)

Privacy Statement *

All information collected by this practice will be used for providing healthcare. Collection, utilization and storage of this information will be compliant with the 2001 Health Records Act.

I consent to Adelaide Urology Care collecting my health information.

I consent correspondence by SMS or email.

Financial Consent *

I understand all consults are associated with a fee which must be paid and settled on the day of the consult

I understand that all procedures fees must be paid upfront prior to surgery and any eligible rebates can be claimed from the Health Fund or Medicare

Cancellation Policy *

I understand I need to provide at least 48 hours notice if I am unable to attend an appointment.

I understand that a $150 establishment fee of will be charged if less than 48 hours notice is given..