TELEHEALTH REQUEST FORM

Please note that due to medicare legislative reform, filling out this form is mandatory for all requests for calls, video consultations, medication repeat requests or minor enquires of existing patients.

There is usually no charge for telehealth or telephone consultations. These appointments are for 5-min consultations only. Consultations lasting more than 5-mins may incur a fee.

First name*

Middle name

Last name*

Date of Birth*

Day

Month

Year

Mobile phone*

Do you consent to us contacting you with regards to your appointment using your phone number listed above?*

Yes

Who do you wish to book a telehealth appointment with?*

Dr Ramy Bishay (Endocrinologist & Bariatric Physician)

Dr Santhi Chalasani (Endocrinologist)

Dr Mehdi Sahebolamri (Endocrinologist)

Dr Mawson Wang (Endocrinologist)

Dr Tavleen Kaur (Endocrinologist)

A/Prof Renuka Shanmugalingam (Renal Physician & Obstetric Physician)

Dr Ali Moghadam (Endocrine, General & Trauma Surgeon)

Mr Tony Saba (Certified Diabetes Educator)

Dr Tomas Megalaa (Senior Podiatrist)

Mrs Ban Hasanin (Dietitian)

Mr Michael Malek (Physiotherapist)

Unsure

Do you consent to us contacting your next of kin regarding this telehealth request if required?*

Yes

Do you consent for your medical information to be uploaded to My Health Records?*

Yes

I have read and agree to the practice's privacy policy (you can access our policies at www.endometabolic.com.au).*

Yes

Do you consent to assign your medicare benefit (item 92440, 91824, 92442, or 92423), for the purposes of bulk-billing your telehealth/telephone appointment, to the treating doctor/clinician?*

Yes

Date

Day

Month

Year

Signature*

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