Book a Consultation (08) 7077 0159
Date of Birth*
Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBangladeshBarbadosBelgiumBelizeBeninBermudaBhutanBoliviaCanadaChinaChileColombiaFranceEgyptEcuadorGabonGermanyGhanaGreeceHungaryHong KongHondurasIcelandIndiaIndonesiaIran, Islamic Republic ofIraqItalyJamaicaJapanJordanKenyaKorea, Democratic People's Republic ofKorea, Republic ofLiberiaMacaoMadagascarMalaysiaMaldivesMaltaMoroccoNamibiaNepalNew ZealandNigerOmanPakistanPanamaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationSamoaSerbiaSingaporeSlovakiaSomaliaSouth AfricaSpainSriLankaSudanSwazilandSwedenTaiwanTogoTokelauTongaTurkeyUgandaUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayVenezuelaViet NamWallis and FutunaWestern SaharaYemenZambiaZimbabwe
Name of Referring Doctor*
Referring Doctor's Clinic
Is this your regular GP yesNo – my regular GP is differentNo – I don’t have a regular GP
If this is not your regular GP, who is your GP?
Physiotherapist (If you have a preferred one)
Medicare Reference (Reference number is the number next to your name on the card)*
Fund Name Select FundACA Health Benefits FundAHM Health InsuranceAustralian Unity Health LimitedBUPA AustraliaCBHS Health FundCDH Benefits FundCUA Health LimitedDefence Health LimitedDoctors Health FundGMF HealthGMHBA LimitedGrand United Corporate HealthHBF HealthHCFHealth Care Insurance LimitedHealth Insurance Fund of AustraliaHealth PartnersLatrobe HealthMedibank PrivateMildura Health FundNavy HealthNIB Health FundPeoplecare Health FundPolice HealthQueensland Country Health FundRailway & Transport Health FundReserve Bank Health SocietySt Lukes HealthmTeachers Health FundTransport HealthTUHWestfund Limited
Concession Card details (if applicable)Pensioner Concession CardCarer’s PensionHealth Care Card
Concession Card Number
DVA Card Number
Approved Claim Number
DiabetesArthritisPrevious Blood Clots in legs (DVT) or lung (PE)Stroke(s)Epilepsy or SeizuresThyroid ConditionsHep B / Hep C / HIVSmoker
If yes, what complication?
GP referred meFriend or family memberSocial MediaMessenger / NewspaperSearch Engine (eg. Google)Seminar or EventOther
ravelled internationally within the last 14 daysBeen in contact with a known COVID patientCurrently have a fever or acute respiratory illnessPlease select if any of the above applies
The consultation and surgical fees charged by Dr Yu are based on the AMA Schedule of Fees, and are as follows: Initial Consult: $180 (Aged Pension $150). Review or Follow-up Consult: $100 (Aged Pension $80).
Please note that whilst we are conducting Telehealth to reduce the spread of COVID19 – there will be no out of pocket expenses for these consults.
PLEASE KINDLY NOTE THAT ACCOUNTS ARE PAYABLE IN FULL ON THE DAY OF CONSULTATION.
It is a term of the provision of these services that the patient shall be liable for all debt collection fees and charges, including but not limited to agent fees, solicitor costs and disbursements in the event that the collection is required. Please note that Medicare does not completely cover the cost of your consultation. I agree to take full responsibility for the prompt payment of all my accounts.
I consent to the release and communication of information from and to any other medical provider, for the purpose of my ongoing clinical management and for ongoing clinical research, audit and education (Letters, Images and Video). Clinical images may be used in a de-identified manner for marketing or education purposes.
I agree with the above*