+61 422 153 727
Please complete this secure form for your IFC Quote
Name of person responsible for anaesthetic fees (and relationship if you are not the patient)
Your phone number
What type of surgery are you having?
Laparoscopic Sleeve Gastrectomy (LSG)Caesarean Section (LSCS)Laparoscopic CholecystectomyLaparoscopic Hernia RepairLaparoscopic FundoplicationGastric BypassBreast SurgeryCosmetic SurgeryDental SurgeryOther
If 'Other' , Please specify
Do you know how long the surgery is expected to take?
If ‘Yes’, please specify
Name of the Hospital where your surgery is taking place
Hunter Valley PrivateLake Macquarie PrivateCharlestown PrivateNewcastle PrivateGosford PrivateLingard PrivateWarners Bay PrivateNewcastle Endoscopy CentreOther
Name of Surgeon
Dr Timothy WrightDr David LoganDr Paul PepperDr Sean FerenczDr Nicole OrganDr Nicholas MoncrieffDr Tony AzziDr Andrew BruntonDr Ed BatemanDr Lyndal Harborneother
Are you in a private health fund?
If ‘Yes’, please enter your Health Fund details (Name and Policy number)
Medicare number and position on card
Any other questions or important information you would like to share?
Disclaimer: Please be aware that this is an ESTIMATE ONLY and may change due to variances in the physical condition of each patient (including age and health), the time required for the procedure and other complexities which may arise.
It is important to be aware that this estimate is for Anaesthetic services only and does not cover additional costs associated with your procedure such as surgical charges, hospital fees or any other expenses.
As Medicare and fund item numbers for anaesthesia include a specific item number, and times may vary even for the same procedure, it is only possible to give an estimate of the likely fee. This estimate may vary from the actual fee charged.
I acknowledge that the information I have provided is correct to the best of my knowledge and I have read and understand the information provided the above disclaimer
PO Box 437, New Lambton, NSW 2305
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