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REVIEW Telehealth and In-person Appointment

Secure your appointment booking now!

Thank you for taking the next step to secure your appointment at Paeds in a Pod. Now we need you to complete a patient registration form, upload your current referral and make a payment.

You also have the option to upload relevant documentation. Once all three steps have been successfully completed, a confirmation email and SMS will be sent within 48 hours outlining your appointment details.

Due to the current demand for services, parents/guardians are given 48 hours to secure their tentative appointment. If this does not occur within the specified timeframe, the tentative appointment is cancelled and offered to the next patient.

Your referral must include the following clinical observations about your child: height, weight, blood pressure, heart rate, and general cardiac assessment so that your consulting specialist can review the information prior to the appointment.

We strongly encourage you to carefully read our Payment Policy and Cancellation Policy to understand your responsibilities.

YOU MUST COMPLETE ALL MANDATORY FIELDS. YOU WILL NOT BE ABLE TO PROGRESS TO THE NEXT STAGE OF THE FORM IF ANY MANDATORY FIELDS ARE LEFT INCOMPLETE.

If you are ready to proceed, please select the ‘Get Started’ button below.

GET STARTED

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REVIEW PATIENT APPOINTMENT PROCESS

Patient Name:*

First Last

Sex:*

Female

Male

This is a required field for script purposes.

Pronoun:*

Patient D.O.B:*

Day

Month

Year

Patient Address:*

Street Address Address Line 2 City State Postcode

REVIEW PATIENT APPOINTMENT PROCESS CONT.

Parent / Guardian Name:*

Prefix First Last

Parent / Guardian D.O.B:*

Day

Month

Year

Home Phone No.*

Mobile Phone No.*

Email Address:*

REVIEW PATIENT APPOINTMENT PROCESS CONT.

GP Name:*

GP Practice:*

REVIEW PATIENT APPOINTMENT PROCESS CONT.

MAIN CONCERNS:

Concern 1:

Concern 2:

MEDICAL HISTORY

Has your child developed a new medical condition or been hospitalised since their last consultation?

YES

If yes, please provide details:

SURGICAL HISTORY

Has your child had any of the following surgeries?

Grommets*

YES

Tonsillectomy*

YES

Adenoidectomy*

YES

Appendix Removal*

YES

Any other surgery?*

YES

If yes, please provide details:

FAMILY HISTORY

IMMUNISATIONS:

Is your child up to date with their immunisations?*

YES

ALLERGIES:

Does your child have any known Allergies? (Food/medication/other)*

YES

If yes, please provide details:

INFORMED CONSENT

With respect to patients, Paeds in a Pod will collect personal information to assist with the provision of health care and directly related services. Instances in which Paeds in a Pod may collect, use or disclose personal information include, but are not limited to:

Use by a multidisciplinary treating team;
Assessment for provision of health care services;
Correspondence with health care professionals, Medicare or your private health fund;
Emergency situations where a patient’s life is at risk and consent cannot be received;
Hospital management processes relating to risk management, safety and security activities, quality assurance and accreditation activities;
Education of health care workers or the placements of students and trainees;
Medical records maintenance as required under our policies and by law; or
Other purposes required or permitted by law.

Dealing with requests from a parent/guardian for information concerning their child.

Before a child has sufficient level of competency, both parents have the right to access health information about their child. This right remains irrespective of whether the parents are separated or divorced, unless a court has directed that a parent has no legal right of access to their child’s health information. If one parent asserts that the other does not have the right to access their child’s health information it will need to be verified with a copy of a court order to that effect. To better understand how Paeds in a Pod deals with court orders visit our website at: https://www.paedsinapod.com.au/separated-parents/

Is there a court order restricting the right of a parent to access this patient’s health information?*

YES

If yes, please provide a copy of the court order

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Is this patient in the care of the Department of Child Safety?*

YES

If yes, please provide the Branch location

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Do you provide permission for the patient’s doctor to correspond with the patient’s school or an education institution/department?*

YES

If yes, please provide the following information

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Is your child a participant of the NDIS?*

YES

Please provide your NDIS number for our records.

If yes, are you self or plan managed? (Please note NDIS Plans are only eligible for Allied Health services)*

PLAN

SELF

Plan Manager Organisation:

Name:

First Last

Contact No:

PLEASE NOTE:

To receive a Medicare rebate the patient must be present at the consultation. Any additional/individual parent/guardian consultations or consultations without the patient present will be charged the full consultation fee and be ineligible to claim a Medicare rebate, e.g. if the parents request separate consultations (for whatever reason) they will each be charged at the normal consultation fee, and only one will be eligible for a Medicare rebate if the patient is present. An administration fee and interest charges will apply where accounts are overdue. For further details, please go to www.paedsinapod.com.au and click on ‘About Us’. Parents/Guardians are advised that there may be additional charges on the day dependent on services provided.

CANCELLATION POLICY*

I agree to the cancellation policy.

Paeds in a Pod’s Payment Policy requires a designated payment in advance for new Telehealth patient appointments. An initial 48-hour tentative appointment will be allocated, providing Parents/Guardians with the time to complete all necessary steps to move forward with securing an appointment.

By making the designated payment in advance, we can provide assurance that an appointment has been secured with one of our Specialists/Allied Health Professionals. We charge a standard fee of $520, with Medicare rebates available at the time of your appointment for patients with a current referral.

Appointments may incur an additional fee based on services provided on the day, the additional amount for services will need to be finalised at the end of your appointment.

In the unlikely event that your appointment may need to be rescheduled or cancelled, you will have the option of accepting an alternative appointment date or have your advanced payment amount refunded in full.

You are responsible for scheduling and attending appointments at the allocated date and time. In the event that an appointment is missed or cancelled at late notice, our Cancellation Policy will take effect and Paeds in a Pod will retain all paid amounts to cover the loss of services incurred on the day.

PAYMENT POLICY*

I agree to the payment policy.

Paeds in a Pod’s Payment Policy requires a designated payment in advance for New In-Person/Telehealth patient appointments. An initial 48-hour tentative appointment will be allocated, providing parents/guardians with the time to complete all necessary steps to move forward with an appointment hold.

An initial deposit payment of $175 + Stripe processing fee of 1.92% ($3.36) is required at the time of your booking to secure and hold the appointment.

A further payment of $345 + a Stripe processing fee of 1.84% ($6.34) is required two weeks prior to the scheduled appointment.

All fees outlined and deposits received are estimates only. There may be some fee variation at the time of the appointment depending on the services provided on the day, which will need to be paid at the end of your appointment.

Medicare rebates are available for patients that are Medicare eligible and have a current referral that meets the appointment criteria. Please note: Medicare rebates can only be processed at the time of your appointment under the Medicare Australia Guidelines.

In the unlikely event that your appointment may need to be rescheduled or cancelled, you will have the option of accepting an alternative appointment date or have your advanced payment amount refunded in full.

You are responsible for scheduling and attending appointments at the allocated date and time, In the event that an appointment is missed or cancelled at late notice, our Cancellation Policy will take effect and Paeds in a Pod will retain all paid amounts to cover the loss of services incurred on the day

For more information about our FEES, please view our website: Our Fees – Paeds in a pod.

Parent/Guardian Name:*

Signature:*

Date*

Parent/Guardian Name:

Signature:

Date

Parent/Guardian Name:

Signature:

Date

By completing this form you agree to Paeds in a Pod contacting you by phone, SMS or email.*

YES

PATIENT REFERRAL

If your child has received new supporting documentation or a new referral is required, please upload these now.

NEW REFERRAL

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 2 MB, Max. files: 1.

DEPOSIT PAYMENT

Please ‘tick’ the box if you understand and agree to these terms and are ready to proceed with payment.*

YES

Patient ID*

Patient ID

Paeds in a Pod is a private billing practice.

By proceeding with this appointment, you agree to the terms of our Payment Policy. All payments must be finalised as part of this appointment confirmation process. Parents/guardians should be advised that there can be some variation in this amount based on services provided on the day, which will need to be finalised at the end of your appointment.

Appointment Deposit Payment$110

Stripe processing fee $2.03

Total $112.23

New In-Person/Telehealth Appointment

Price:

Credit Card

Stripe processing fee details: 1.92% ($3.36).