Patient Intake Form (Child)

Please fill out all required fields below and submit your form prior to your child’s appointment. When selecting dates greater than one year prior, click the year field and manually type in the relevant year to quickly access the date.

Fees & Acceptance Of Terms

The full fee is payable on the day of consultation by cash, cheque, credit card or EFTPOS. Cards accepted are VISA, MasterCard. We do not accept Diners & Amex cards.

In the event where your overdue account is referred to a collection agency and/or law form, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs.

Initial Consultation = $260.00 • Medicare Rebate = $75.05 • Patient Contribution = $184.95
Review Consultation = $160.00 • Medicare Rebate = $37.70 • Patient Contribution = $122.30