Iron Infusion Booking

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Are you a new patient at Highgate Health? *

YesNo

Have you had an appointment with Highgate Health in last 4 Months? *

Yes NoNot Sure

Title *

Gender *

First Name *

Middle Name

Last Name *Please use legal name as per Medicare (No hyphens please)

Preferred Name

Date of Birth *

Mobile Number *no spaces please e.g. 0432123123

Email Address *

Home address *Street address line 2

Suburb *

State *

Postcode *

Country

How did you hear about Highgate Health? *

Google.Facebook / Instagram.Friend.Referral from Medical Practitioner.Other.

Do you have Medicare Card? *

YesNo

Medicare card number *

What number are you on the card? *

Important Information :

There are no Medicare or Private Health Fund rebates available.
A referral is not necessary

Options	Monday - Friday	Saturday
1 - Infusions only - I will supply the medication	$165.00	$180.00
2*- I would like Highgate Health to supply the medication	$232.70	$247.70

*This may vary depending on you if you are entiled to Medicare PBS. Standard PBS is $31.60. The cost of the iron without PBS is +$320

Which Options would you like

1. I have the iron medication and will bring to the infusion.2. I would like Highgate Health to provide the iron medication for me.

I understand that I need to bring recent blood results (last three months) and iron medication to the infusions *

I understand that I need to bring recent blood results (last 3 months) to the infusions and happy to pay for the Iron medication costs and the $30.00 service fee to supply the iron *

Please upload any other documents e.g. Pathlogy results or referral

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Please add any documents now so they can be uploaded into your patient records

Any further information or comments.

I have read and agree to the :

Medical Practice Privacy and Telehealth Consent Form

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