Surgical Patient Registration Form

We respect your right to privacy and take our privacy obligations seriously. We comply with the Australian Privacy Principles under the Privacy Act 1988 (Cth). Our Privacy Policy is available for review on our website. We require your consent to collect, use, and disclose your personal and health information. Please read the following information carefully and sign where indicated.

We collect your personal and health information, including your full medical history, for the primary purpose of providing you with healthcare services. This information is necessary to ensure safe, appropriate, and effective care. In addition, your information may be used for the following purposes:

Practice management, including clinical audits, accreditation processes, staff training, and billing activities.

Communication with third parties, such as Medicare Australia, private health insurers, government departments, and other healthcare practitioners involved in your care.

Post-operative care, where you may choose to contact us with questions or submit clinical photographs via email or mobile phone. By signing this form and electing to transmit images or information electronically, you acknowledge and consent to these materials being shared with relevant clinicians (including via mobile devices, email, or tablets) to allow timely review and appropriate care.

Use of AI-assisted clinical transcription, where our clinic utilises generative AI transcription technology to assist in generating medical notes (similar to a clinical scribe). This technology uses natural language processing to transcribe consultations accurately. The final transcribed medical note is retained in your patient record; audio recordings and voice data used by the AI are deleted and not stored.

Please note that any statement of services rendered does not constitute a guarantee or promise of outcome. Individual biological differences and clinical factors may influence treatment results, and treatment plans or expectations may change as care progresses. In some circumstances, repeated or updated informed consent may be required.

As a service to our patients, FNQ Plastic Surgery & MediSpa provides a surgical fee estimate outlining the likely medical costs associated with your in-hospital or day-case procedure.

We strongly recommend that you discuss these costs with FNQ Plastic Surgery staff prior to your procedure to ensure you understand all fees involved. Please note that you will incur out-of-pocket expenses and will be responsible for any costs not covered by Medicare or your Private Health Fund.

You should contact your Private Health Fund directly and quote the item numbers listed on your fee estimate to confirm your rebate and any out-of-pocket expenses.

Medicare item numbers are five-digit numbers that apply only to procedures listed in the Commonwealth Department of Health Medicare Benefits Schedule and are subject to strict eligibility criteria. Fees are billed in accordance with the AMA Fee Schedule. Where more than one Medicare item number applies, fees are calculated as follows:

• 100% for the first item
• 50% for the second item
• 25% for the third and subsequent items

Please note that the fee estimate provided is an estimate only of the fees charged by FNQ Plastic Surgery & MediSpa. Unless otherwise stated, it does not include fees charged by other medical providers, such as anaesthetists, radiologists, nuclear medicine physicians, or pathologists, nor does it include hospital-related costs such as accommodation or pharmacy charges.

• Self-funded patients should contact Cairns Private Hospital on (07) 4052 5109 to obtain a hospital cost estimate.
• If your procedure involves general anaesthesia or sedation, please contact Cairns Anaesthetic Group on (07) 4044 6900 to obtain an anaesthetic fee estimate.

If unforeseen circumstances arise during your procedure, additional medical services may be required. In such cases, additional fees may apply and may not be covered by this estimate. If further surgery is requested or required on the day of your procedure, appropriate additional fees will be incurred.

This practice requires full pre-payment of fees at least seven (7) days prior to the procedure date. Payment may be made via credit card over the phone or by direct bank transfer using the details provided. Please note that the full invoiced amount must be paid upfront. Any applicable Medicare or Private Health Fund rebates will be processed after surgery.

I consent to assign my right to Medicare benefits to my private health insurer or approved billing agent for any professional services provided to me as part of my hospital or hospital‑substitute treatment, including associated pathology, diagnostic imaging and referred services. I understand this assignment allows my insurer or billing agent to process Medicare and private health insurance benefits on my behalf. I confirm I have received information about the expected fees and charges, the providers involved, and the treatment to be covered by this assignment. I approve this assignment and understand it must be completed before any simplified billing (including ECLIPSE) claim is submitted.

In connection with the medical services I am receiving, I consent to photographs and/or videos being taken of me or parts of my body under the following conditions:

A. Photographs and/or videos may be taken only with the consent of my treating surgeon and at a time and under conditions approved by them.

B. Photographs and/or videos will be taken by my surgeon or by a photographer approved by my surgeon.

C. By consenting to this, I acknowledge and consent that these images will form part of my confidential medical record.