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Telehealth Request Form

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Telehealth Request Form

Due to Medicare legislative reform, this form is mandatory for requests for calls, video consultations, prescriptions or minor enquiries from existing patients. Telehealth and telephone consultations are generally provided without charge for consultations of up to five minutes. Longer consultations may incur a fee.

Patient Information

Please enter your details as registered with Medicare
Full Name
Do you consent to us contacting you with regards to your appointment using one of your phone numbers listed above?

Appointment Details

Select the clinician you would like to speak with.
Who do you wish to book an appointment with (you can pick more than one)?

Consent & Communication

Please review each question and select your response.
Do you consent to us contacting your next of kin regarding this telehealth request if required?
Do you consent for your medical information to be uploaded to My Health Records?
I have read and agree to the practice's privacy policy (you can access our policies at www.endometabolic.com.au).
Do you consent to assign your medicare benefit (item 92440, 91824, 92442, or 92423), for the purposes of bulk-billing your telehealth/telephone appointment, to the treating doctor/clinician?

Confirmation

Complete the date and provide your signature
Date

Telehealth

Complete the information below and our team will review your request.

STEP 01

Patient information

STEP 02

Select your clinician

STEP 03

Consent & communication

STEP 04

Date & signature

CONTACT

02 9755 9764

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