Patient Registration Form
Please complete the registration form attached promptly and return to us prior to your appointment.  
Fees:
Initial consultation (item 104) = $250
Review Consultation (item 105) = $150
(Pensioner, Disability, HCC Government card holders - item 104 ($230) and item 105 ($130))

Please note where extra services and/or treatment are provided additional fees may apply. These fees are determined by Mr Zeev Duieb.  Payment is required on the day of consultation. Mr Duieb does not routinely Bulk Bill patients. Mr Duieb does not claim on your behalf from third parties such as TAC or Workcover. If your visit relates to a transport accident claim or a workplace injury, you will be required to pay for the consultation and claim the payment back.

Before your consultation, you might be asked to make preparations. For instance, some conditions like haemorrhoids will require preparation with a Microlax enema. You should administer this about 2 hours before your appointment. This helps with examination and assessment when you visit your surgeon.

A text reminder will be sent to you in the week prior to your appointment. Please ensure you reply to confirm your consultation. Failure to confirm your appointment may result in your appointment being cancelled. Less than 24hr notice of cancellation, a $50 fee may apply.

* Please email a copy of your referral letter before your appointment to info@drzeevsurgery.com 
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Title and Given Names
Surname
Date of Birth
Occupation
Address and Post Code
Email Address
Phone Number
Emergency Contact Details:
-Name and Contact Number
-Relationship to you
Health Fund &  Membership Number
Medicare Card Number and Expiry Date
If Aged Pensioner/ DVA Gold, provide card number/ 
If TAC or Workcover, provide insurance name and claim number
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