Patient Registration Form

How Did You Hear About Dr George Awwad?
(Please tick all relevant options:)

In your own words, why are you seeing Dr Awwad?

Relationship to patient

If the patient is a minor

Mother / Father / Guardian’s Full Name

Parent/Guardian’s: Medicare Number

Please complete the following information if this relates to a workcover or third party claim:

Is this claim: A workcover injury

Yes No

Solicitor: (if Applicable)

Documentation from the insurance company supporting acceptance of your claim MUST be provided, or the onus will be upon you to settle the account on the day of consultation. Please note that although this may be a claim, the final responsibility for payment does fall on the patient*

General Information and Fees
Medicare does not completely cover the cost of your consultation. The consultation fees charged by Dr Awwad are as follows:

Initial Consultation:$200.00
Follow Up Consultations: $80.00
Pension Card Holder: $170.00
Second Opinion Consultation: $300.00

I understand that payment in full of the account is my responsibility and a gap will be charged above the Medicare Rebate. Failure to pay accounts will result in legal action / debt collection which incurs an additional charge by myself. In engaging Dr Awwad, I acknowledge that my contractual relations are with the Medical Practitioner and not Orthopaedics SA Pty Ltd and I further acknowledge that Orthopaedics SA is not the provider of the medical services.

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