As Soon As You Book For Your Procedure. Please Give My Rooms a Ring and My Friendly Staff Will Arrange a Consultation

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1 Dr. Adel Tanious FANZCA Specialist Anaesthetist Provider No: T Ph: Fax: PO Box 54 Introduction and Information about Fasting Instruction and Anaesthetic Fees Dear Patient Firstly I would like to introduce myself. My name is Dr. Adel Tanious and I will be your anaesthetist for your forthcoming. I strongly believe that I need to have a better understanding of your health condition to be able to ensure a safe and comfortable anaesthetic. I therefore need to communicate with you in order to minimise the chance of delaying or postponing the procedures. As Soon As You Book For Your Procedure Please Give My Rooms a Ring and My Friendly Staff Will Arrange a Consultation Phone no.: Office Hours Tuesday Friday 9.00am 3.00pm My rooms are located at 127 Torquay Road, Scarness - Hervey Bay Fasting Instructions: - For a Morning Operation: - No food after midnight but clear fluids (water, apple juice, black coffee or tea) may be consumed until 4 hours before the. For an Afternoon Operation: - You can have a light breakfast as long as it is 6 hours before the Eg. White Toast and Spreads. But clear fluids (water, apple juice, black coffee or tea) may be consumed until 4 hours before the. Medication and condition:- It is very important to notify me if you are a diabetic or on any blood thinning medication: eg. Aspirin, Clopidogrel (Iscover/Plavix), Asasantin or Warfarin 1

2 Anaesthetic Fees: - Please read carefully, complete and post the Financial Consent attached Anaesthetic fees are calculated according to time and complexity. Therefore, we can only provide you with an estimated cost of the anaesthetic prior to the actual. A personalised account will be sent to you after we receive your booking. You are kindly requested to pay this estimated fee PRIOR to your. All DVA and Work Cover patient accounts will be submitted directly to their respective health insurer. All other patients will be charged the estimated fees prior to the. Your personal out-ofpocket contribution will be influenced by your insurance. Self Funded Patients: All Self funded patients will need to pay the full estimated fee prior to the. After your another invoice will be sent to you. Once it is paid in full, you will receive a final receipt enabling you to claim your rebate from Medicare. Health Funds accepting Co-Payment (E.g. MBP, BUPA, AHSA group) This co-payment is very beneficial as it maximises the health fund rebate and minimises the patient s out-of-pocket contribution. If you are a member of one of these health funds you will only be required to pay the co-payment prior to the procedure. After the procedure another invoice will be sent directly to your health fund. This co-payment will vary depending on the time and complexity of the procedure and may range from $50 to $400. In case of Teeth extraction, your out-of-pocket contribution is $250-$350 for all major Health Funds. Health Funds not accepting Co-Payment (E.g. NIB, HBA, HCF, MU) However, if your health fund does not accept a co-payment you will need to pay the full estimated fee prior to the. This may range from $395 - $650 for a minor and $655 - $1500 for a major. After your another invoice will be sent to you. Once it is paid in full, you will receive a receipt enabling you to claim your rebate from Medicare and your Health Fund. Please note: in the majority of cases the estimated fees closely approximate the final one Your out-of-pocket and non-refundable contribution will be higher due to your health fund paying you less. This contribution may range from $200 for a minor to $700 for a major. In case of Teeth extraction your full fee is. The following is an example only. Health Funds accepting Co- Payment Health Funds not accepting Co-Payment Self Funded Patients Time Operation Anaesthetic Fees Teeth teeth teeth To be paid Prior to To be paid Prior to Out-Of-Pocket Contribution $250-$350 To be paid prior to About $360 About $0 I hope this guide is useful to you. If you have any further questions please phone my rooms on Our office hours are 9:00 AM to 3:00 PM from Tuesday to Friday. you can phone Monday to Friday from 9:00 AM to 5:00 PM. 2

3 PRE-OPERATIVE ASSESSMENT QUESTIONNAIRE Dr. Adel Tanious Patient Name: Date of Birth: Address: Suburb/City: State: Post code: Phone Nos: Home: Work: Mobile: Your GP Name & Phone No: Name Of Operation: Date Of Operation: Surgeon: Hospital: Medicare No: Ref No: Name and Number of Private Health Fund: Address: Emergency Contact Name and Phone Number: 1. List ALL MEDICATIONS you are currently taking (including over the counter, herbal/alternative medicines and/or pain killer). State dosage and strength. 2. List previous s including approximate dates. Yes No 3. Have you, or a relative had any complications with an anaesthetic or s? If yes, give details 4. Do you have any allergies to medications, latex, rubber and/or tropical fruits? If yes please list. 5. Do you currently have, or ever had, any of the following conditions? (Circle the specific condition and/or mark the applicable box with x) Angina/Coronary Disease/Heart Attack/Cardiac Surgery/Pacemaker Rheumatic Fever/Heart Murmurs/Palpitations High Blood Pressure Asthma/Chronic Bronchitis/Emphysema/Tuberculosis Other Lung Disease Sleep Apnoea Cough, Cold or Flu in the past 3 weeks Blood Clot in the Legs or Lungs (Thrombosis or Embolism) Blood Disease/Bleeding, Bruising problems/haemophilia/anaemia Have you Taken Aspirin/Warfarin within the past 5 days Please see the back Continue Question No. 5 3 Please Turn The Page

4 Stroke/Blackouts/Fits/Epilepsy Mental Health Condition eg. Depression, Schizophrenia Heartburn/Gastric Reflux/Hiatus Hernia/Peptic or Duodenal Ulcer Bowel Problems eg. Diverticulitis, Crohn s Hepatitis/Jaundice/Liver Disease Yes No Diabetes (Please circle treatment) Insulin / Tablets / Diet Have you recently taken Steroid (Cortisone/Prednisone) medication? Do you take Hormone replacement therapy? If yes, please list Arthritis/ Muscles Disease Do you have difficulty walking up a flight of stairs or 1 Kilometre? Any inherited disorder. (eg. Porphyria, Haemochromatosis, Thalassemia)_ Kidney/Bladder problems Are you pregnant? Do you get Motion sickness? Have you been overseas within the last 2 weeks? Do you smoke? If yes, How many per day Have you ever smoked? If yes, when did you cease? Do you use recreation drugs? If yes, which drug(s) and how often Do you consume Alcohol? If yes, how often Daily Weekly Monthly How much? Do you wear or have any of the following: (please circle) Hearing Aid Contact Lenses Denture Loose Teeth Dental Bridges Crowns Caps Artificial Eye Other Prostheses Have you lost weight recently without trying? If yes, how much Have you been eating poorly because of a decreased appetite? Are there any other health problems of which your Anaesthetist should be aware? If Yes, Please List Your Weight Your Height The information I have supplied in this questionnaire is accurate to the best of my knowledge. Patient Name: Sign: Date: If you have any inquiries, please ring the practice on or It is helpful to your Anaesthetist to have this information well in advance. 4

5 Patient Financial Consent Dr. Adel Tanious FANZCA Specialist Anaesthetist Provider No: T Ph: Fax: PO. Box 54 Patient Name: Phone no: Mobile no: Operation Date: I understand the costs are an estimate and may be subject to variation. I acknowledge that it is my responsibility to confirm with my health insurance fund the level of cover that I have and any amount that it will be my responsibility to pay. I understand that this document is not consent to, nor a request for, a procedure. Patient or Guardian s signature: Date: Patient or Guardian s full name: Please sign this Financial Consent and attach it with the Pre-Operative Assessment Questionnaire and You can either Post it to: Dr. Adel Tanious PO Box 54 Fax it to: it to: Drop it in to: 127 Torquay Road, Scarness QLD 4655 Office hours: Tue-Fri 9am-3pm 5

As Soon As You Book For Your Procedure. Please Give My Rooms a Ring and My Friendly Staff Will Arrange a Consultation

As Soon As You Book For Your Procedure. Please Give My Rooms a Ring and My Friendly Staff Will Arrange a Consultation Dr. Adel Tanious FANZCA Specialist Anaesthetist Provider No: 2477954T Ph: 07 4128 2550 Fax: 07 4124 0496 admin@anacare.com.au www.anacare.com.au PO. Box 54 Introduction and Information about Fasting Instruction

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