New Patient Anaesthetic Estimate Form

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Medicare Number

Private Health Fund

Health Fund Member Number

Procedure Details

Referring Specialist

Prefix First Last

Procedure Name

Procedure Date (if known)

Hospital Name

Estimate Request

Please indicate what you would like an estimate for:

Full Anaesthetic Fee (Uninsured or Super release)

Out-of-Pocket Costs (If appropriate health fund coverage applies)

Additional Notes (if any):

Important Information

For most procedures, our Anaesthetists participate in the Known Gap scheme with private health funds. This means we bill Medicare and your health fund directly, and you are only responsible for the out-of-pocket portion.

However, depending on the type, duration, and complexity of the procedure, the Anaesthetist may request the full fee to be paid by the patient. If this applies to your case, we will provide a detailed estimate outlining the total cost and any rebates available.

If you have questions about your coverage or estimate, please contact our team.

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