• Patient Registration Form

Patient Information for Dr Navi Bali – Orthopaedic Surgeon

You may wish to complete this online Patient Registration Form prior to your appointment. Forms are sent using TLS encryption protocols and a copy is sent to the email address nominated in the form.

Alternatively, you may download a PDF version of this form, complete it and bring it with you on the day of your appointment.

  Patient Registration Form PDF

Please complete at least one contact phone number.





If patient is a minor (under 18)


Workers Compensation (if applicable)


FINANCIAL INFORMATION

Medicare does not completely cover the cost of your consultation. The consultation fee’s charged by Dr Elix are as follows and are payable IN FULL on the day of consultation by EFTPOS only. No cash is kept on the premises.

Initial Consultation - $200.00 ($75.05 rebate) Review Consultation - $110.00 ($37.70 rebate)

Deviation to the above fees may occur e.g. Second opinions and multiple injuries subject to the Doctors discretion. Other fees may be incurred for plaster casts, boots, injections, splints etc. It is a term of the provision of these services that the patient shall be liable for all debt collection fees and charges if required. I understand that payment of the account in full is my responsibility (not applicable for accepted Workcover claims, Defence Personal, DVA card holders).

CONSENT

I consent to the release and communication of information from or to any other medical provider for the purpose of my ongoing clinical management, ongoing clinical care and audit.

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DARWIN ORTHOPAEDICS

Darwin Private Hospital
Ground Floor
Rocklands Drive
Tiwi NT 0810

Ph: (08) 8920 6351
Fax: (08) 8920 6216

  Getting Here

HERVEY BAY ORTHOPAEDICS

7 Madsen Medical
Opposite Hervey Bay Hospital
Hershel Court
Urraween QLD 4655

Ph: (07) 4124 8444
Fax: (07) 4124 8411

  Getting Here

  Hervey Bay Orthopaedics Website

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