Patient Booking Form

Essential Anaesthetic Services

Patient Booking Form

Your surgeon has booked you in for a procedure. We are the anaesthetists looking after you on the day. Please complete this form so we can prepare your anaesthetic account before you arrive.

Please complete this as soon as you can. The sooner we have your details, the sooner we can confirm in writing what your anaesthetic will cost and what you can expect to pay — your informed financial consent — and prepare properly for your procedure. It takes about 5 minutes. You will need your Medicare card, and your health fund, DVA or claim details if they apply.
1 Your procedure

These details come from your surgeon’s rooms. If you are not sure of the exact date or the name of the procedure, put what you were told.

The day you are booked in for surgery.

In your surgeon’s words — for example “right knee arthroscopy” or “cataract, left eye”.

2 Patient details

Please give the patient’s name exactly as it appears on their Medicare card. A name that does not match the card will hold up the claim.

3 How we reach you

We use these to send your account and, if anything is unclear, to call you before the day.

Your account and receipt are emailed here.

4 Address

This must be the patient’s residential address as recorded with Medicare. Medicare will not accept a PO box on an anaesthetic claim.

Unit or street number and street name — not a PO box, locked bag or private bag.

Postal address

A PO box is fine here — this is only where we send mail.

5 Medicare card

Copy these straight off the card. The reference number is the small digit printed to the left of the patient’s name.

All 10 digits, no spaces.

6 How your account will be paid

Choose the one that applies. We will confirm what you can expect to pay before your procedure — you will not get a surprise on the day.

Your health fund

Choose your fund and copy the membership number from your card.

Your DVA card

Your claim

We bill the insurer directly. We need the claim open and approved before the procedure.

Concession card

Only if you hold one — it can change what you pay.

Public patient

If you are being treated as a public patient there is normally no anaesthetic account from us. Please still send the form — we will check the booking and contact you if anything is needed.

7 Before you send

How we use these details. Essential Anaesthetic Services collects the information on this form so we can plan and provide your anaesthetic care, confirm with you before your procedure what it will cost and what you can expect to pay, and bill for it afterwards. Some of it — your Medicare card details, and the patient’s name exactly as it appears on the card — is required before Medicare or your fund will accept a claim, and we cannot prepare your estimate or your account without the rest. If you would rather not fill this in online, please phone our rooms and we will take your details over the phone.

We share what we need to with the people involved in your care and your account: your anaesthetist, Medicare, and your health fund, DVA or insurer where those apply. We also use specialist booking and billing software, so the companies that supply and support that software can reach it. Those systems run on Australian infrastructure, and the companies behind them work internationally — their support staff may need to reach our systems from other states or from overseas.

We do not use your information for marketing and we do not sell it. You can ask us what we hold about you, ask us to correct it, or raise a concern about how we have handled it — please contact our rooms and we will help.

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Essential Anaesthetic Services · Bendigo, Victoria

Want to Print Out a Booking Form to Complete?

Download our booking form below.

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