Your anaesthetic booking form

This form takes about ten minutes and does two important jobs: it gives your anaesthetist your health details so your anaesthetic can be planned for you specifically, and it gives our team your fund details so your written fee estimate — your informed financial consent — can be prepared before the day.

Have these handy before you start: your Medicare card, your health fund membership card (or DVA / WorkCover / TAC details), your surgeon's name and procedure date, and a list of your medications.

How we handle your information: Essential Anaesthetic Services collects the personal and health information in this form to plan and provide your anaesthetic care, prepare your informed financial consent, and process your account with Medicare, your health fund or other payer. It is handled confidentially by our clinical and accounts team, stored securely, and not used for any other purpose. Full details — including how to access or correct your information — are in our privacy policy. Questions first? Call (03) 8595 5350.

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Patient Details

Name

First

Last

Email Address

Confirm Email

Date of Birth

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number

Medicare Number

Medicare Reference number

Health Fund

Membership Number

Level of Cover

Full Age Pension Number

DVA Pensioner Card Number

Is this a WorkCover or TAC claim? If so please add number

Person responsible for account:

Address if different to patient

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Surgery Details

Surgeon Name

Date of Operation

Procedure

Account Processing

Prefer paper?

Download and print the booking form, complete it, and bring it with you or post it to 97 Forest St, Bendigo VIC 3550.

Download the PDF booking form

What happens after you submit

Our team checks your details and your fund's gap-cover arrangement.
You receive your written fee estimate — your informed financial consent — before your procedure. How fees work.
Your anaesthetist reviews your health information before they meet you on the day. How to prepare.