New Patient Form

    Patient Details

    Health Insurance

    Please present Aged or Disability Pension Cards to Reception.


    A current referral is required for you to claim Medicare rebates. Please note a referral from a general practitioner is generally valid for 12 months but may be deemed indefinite if specified by your GP. A referral from a specialist is valid for only 3 months. It is your responsibility as the patient to provide an up-to-date referral letter to your treating specialist.


    • All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

    • Informed Financial Consents will be provided for all surgical procedures which will incur an out of pocket expense. These require signature and a copy will be retained by Geelong Urology.

    • Please note: Our estimate of fees for surgery do not include Health Fund excess fees, Anaesthetist, Assistant or Pathology fees. Please speak to our office staff for other provider contact details. Assistant fees are usually charged at approximately 1/5th of the surgeon’s fee.

    • Invoices for surgery will be forwarded to the nominated health fund (with some exceptions) and out of pocket expenses will be directly billed to the patient.

    • All consultations/procedures in rooms are payable on the day.

    • In some instances, a deposit will be required prior to surgery.

    • If you are not covered by health insurance, all surgical fees must be paid in full prior to surgery.

    • All other invoices are payable within two weeks of date of invoice.

    • Unpaid invoices will automatically be sent to a third-party debt collection agency and administration fees may be added to your account.

    • Some nurse specialist appointments may incur a fee, these will be explained to you at the time of the booking.

    CONSENT FOR RELEASE OF INFORMATION It is an increasingly important part of a surgical practice to perform quality assurance projects and these include clinical audits. This means critically looking at procedures that are performed and discussing any issues that may have arisen so that these could be prevented in the future. These audits must be peer reviewed in order for them to be deemed suitable by the Royal Australasian College of Surgeons. As such some of this information is presented in front of other colleagues and urologists. At no time are patients’ identities mentioned during these discussions but simply a general discussion regarding the type of cases that have been performed and problems that may have arisen. With the current privacy legislation, it is imperative that we have your informed consent to perform these audits and that you agree that information that may be obtained from these audits is allowed to be presented in front of third parties such as other urologists. Our Privacy Policy is available to be viewed at our practice, or is available to you at your request.

    I agree to the collection use and disclosure of medical information collected about me by Geelong Urology so that you may properly assess, diagnose and treat, and be pro-active in my health care needs.