Patient Registration - ENT Clinic Melbourne | Dr Charles Giddings & Associate Professor Joanne Rimmer

Name*

Prefix First Last

Date of Birth

Email*

Telephone (Home)

Telephone (Mobile)

Address

Street Address City Postal Code

Indigenous Status

Aboriginal
Torres Strait Islander
Neither
Not stated

(Select all that apply)

Medicare Number

Ref#

Expiry Date

Private Health Fund

Private Health Membership number

Veterans' Affairs (if applicable)

Card Type

Gold
White
Blue

Next of kin

Telephone number

Parent / Guardian details

(If patient is under 18 years old)

Name

First Last

Date of Birth

Address

Street Address Postal Code

Phone (if different from above)

Email (if different from above)

Medicare Number

Ref#

By submitting this form, I acknowledge the Consulting Fees and agree with my information being held by The ENT Clinic. Please contact the front desk staff prior to submitting this registration should you have any queries.*

Yes

	FEE	Medicare rebate	Out of pocket (estimate)
New patient (104)	$240.00	$78.05	$161.95
Review (105)	$135.00	$39.25	$95.75
Endoscopy (41764)	$220.00	$110.40	$109.60
Phone Review (91833)	$70.00	$39.25	$30.75
Ear toilet (41647)	$165.00 ($82.50 2nd ear)	$98.75 ($49.35 2nd ear)	$65.25 ($30.65 2nd ear)
Nasal cautery (41677)	$145.00	$80.90	$64.10
Videostroboscopy (41501)	$260.00	$166.80	$93.20
Intratympanic steroids	$255.00	$98.75	$156.25
Skin Lesion Biopsy (30071)	$130.00	$46.95	$83.05
Oral Cavity Lesion Biopsy (45801)	$255.00	$114.10	$140.90
MEVT (Grommet) (41632) in chair	$355.00	$214.60	$140.40

*Fees correct from 01 July 2022 and may be subject to change without prior notice

Fee Schedule

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Name

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The ENT Clinic patient registration form

Parent / Guardian details