Online Medical Consultation - National Telemedicine Doctors

Step 1 of 16

Are you a new patient to our practice?*
- Yes
- No

We are committed to protecting your privacy and know it is important for you to understand how your information is handled.
In submitting the information contained in this form, you:*
Acknowledge that your health practitioner and National Telemedicine Doctors will collect such information (including any personal or sensitive information), for the purposes of providing you with health services or enabling any related communications; and
Consent*
Consent to National Telemedicine Doctor’s Terms & Conditions, and to National Telemedicine Doctors handling your personal and sensitive information in accordance with its Privacy Policy.*

To complete this form you may need:
- Medicare card
- Pension/Healthcare/Concession card
Please make sure you have any relevant items ready before you begin.

To protect your personal information this form will clear and reset after 4 minutes of inactivity.

All fields marked with an asterisk (*) are required.

Personal Details
Title
First name*
Last name*
Preferred name
Gender*
- Female
- Male
Date of birth*

DD
MM
YYYY
Occupation
Street address*
Street address line 2
Suburb*
State*
Postcode*
Email address*
Mobile phone

Emergency Contact Information
We collect this information in case of an emergency
Next of kin
Next of kin – First name*
Next of kin – Last name*
Next of kin – Relationship*
Next of kin – Contact number*
Emergency contact
Same as Next of kin
- Same as Next of kin
Emergency contact – First name*
Emergency contact – Last name*
Emergency contact – Relationship*
Emergency contact – Contact number*

Your Health History
Do you have any allergies or are you sensitive to drugs or dressings*
- Yes
- No
Please list*

Social Activities
Do you smoke?*
- No
- Yes
- Ex Smoker
How frequently do you smoke? (eg 2 cigarettes daily/weekly)*
If you’re an ex smoker, can you please provide the approximate date that you ceased smoking?*

DD
MM
YYYY
Do you drink alcohol?*
- No
- Yes
How often do you have a drink containing alcohol?*
How many standard drinks containing alcohol do you have on a typical day?*
How often do you have six or more drinks in one occasion?*
Are you concerned about drinking?*
- Yes
- No

Which service do you require today?
Which service do you require today?
Quick Prescription Service

for a repeat prescription/medication
you already know
Absence From Work Certificate

For certificates to cover more than 1 day,
please book a "Telehealth GP Appt" instead
Telehealth GP Appointment- 10 Mins

(General Consults, Prescriptions,
Absence From Work Certificate,
Referral to Specialists/Allied Health,
Referral for Blood Tests and X-rays)

(Strictly no Drugs of Addiction prescribed)
(No Vaccine Exemption certificate
issued under this appointment type)
Telehealth GP Long Consult- 25 Mins

(General Consults, Prescriptions,
Absence From Work Certificate,
Referral to Specialists/Allied Health,
Referral for Blood Tests and X-rays)

(Strictly no Drugs of Addiction prescribed)
(No Vaccine Exemption certificate
issued under this appointment type)
COVID-19 Vaccine Exemption Certificate
Telehealth Psychologist Appt - New Patient
Telehealth Psychologist Appt - 30 Mins
Telehealth Dietitian Appt - New Patient
Telehealth Dietitian Appt - 30 Mins
Which service do you require today?*
- Quick Prescription Service
- Absence From Work Certificate
- Telehealth GP Appointment- 10 Mins
- Telehealth GP Long Consult- 25 Mins
- COVID-19 Vaccine Exemption Certificate
- Telehealth Psychologist Appt - New Patient
- Telehealth Psychologist Appt - 30 Mins
- Telehealth Dietitian Appt - New Patient
- Telehealth Dietitian Appt - 30 Mins

Medicine Category:

Sub-category: NA

Sub- sub category: NA

Selected Medicine:

Requested Medication Details:

Answers to the questions asked-

Select Medicine Category

Select a sub-category

Select a sub- sub category

Select Your Medication

Requested Medicine

Please answer the questions below:

Regarding Medicare Rebate
You might be eligible for a $89.65 Medicare Rebate if you have a valid Medicare card and referral (Care Plan) from a GP through a Mental Health Care Plan (MHCP).

If you wish the $89.65 Medicare rebate to be paid directly into your bank account following the consultation, please provide us with the following details:
You might be eligible for a 63.55 Medicare Rebate if you have a valid Medicare card and referral (Care Plan) from a GP through a Mental Health Care Plan (MHCP).

If you wish the $63.55 Medicare rebate to be paid directly into your bank account following the consultation, please provide us with the following details:
Please upload below a copy of your referral (Care Plan) from a GP through a Mental Health Care Plan (MHCP):

(Files must be less than 2 MB. Allowed file types: pdf, png and jpg)
Attach File
Drop files here or

Accepted file types: pdf, jpg, png, jpeg.
If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below:
Medicare card - Number:
Medicare card – Position on card:
Medicare card – Expiry date:

DD
MM
YYYY
Have you already updated your bank account details with Medicare?
- Yes
- No
IMPORTANT

If you do not provide us with the above details and have not already updated your bank account details with Medicare, we cannot process payment of the Medicare rebate directly into your account. Instead, we can provide you with a receipt for the consultation, with which you can claim the rebate from Medicare directly yourself, provided you are eligible for the rebate.

Regarding Medicare Rebate
You might be eligible for a $56 Medicare Rebate if you have a valid Medicare card and referral (Care Plan) from a GP through a Chronic Disease Management Plan (CDMP).

If you wish the $56 Medicare rebate to be paid directly into your bank account following the consultation, please provide us with the following details:
You might be eligible for a $56 Medicare Rebate if you have a valid Medicare card and referral (Care Plan) from a GP through a Chronic Disease Management Plan (CDMP).

If you wish the $56 Medicare rebate to be paid directly into your bank account following the consultation, please provide us with the following details:
Please upload below a copy of your referral (Care Plan) from a GP through a Chronic Disease Management Plan (CDMP):

(Files must be less than 2 MB. Allowed file types: pdf, png and jpg)
Attach File
Drop files here or

Accepted file types: pdf, jpg, png, jpeg.
If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below:
Medicare card - Number:
Medicare card – Position on card:
Medicare card – Expiry date:

DD
MM
YYYY
Have you already updated your bank account details with Medicare?
- Yes
- No
IMPORTANT

If you do not provide us with the above details and have not already updated your bank account details with Medicare, we cannot process payment of the Medicare rebate directly into your account. Instead, we can provide you with a receipt for the consultation, with which you can claim the rebate from Medicare directly yourself, provided you are eligible for the rebate.

What is the official date you tested positive to COVID-19 (Coronavirus) ?*
Date Format: DD slash MM slash YYYY
Please upload below a copy of your COVID-19 (PCR test or RAT test) result :

(Files must be less than 2 MB. Allowed file types: pdf, png and jpg)
Attach File*
Drop files here or

Accepted file types: pdf, jpg, png, jpeg.
Also, if applicable – please upload below a copy of evidence of the registration of your result with relevant state health department :
Attach File*
Drop files here or

Accepted file types: pdf, jpg, png, jpeg.
Please note:

The maximum period of exemption following a confirmed SARS-CoV-2 infection is 6 months from the date of diagnosis.

(Must be confirmed with PCR test OR RAT test that has been registered with relevant state health department)

The Australian Immunisation Register is linked to your Medicare records. You can access your exemption either through your my.gov.au account or by downloading the Medicare app to your phone - navigate to the section marked “Proof of vaccinations”.

The ATAGI advice is not that it’s recommended to withhold vaccination following a SARS-CoV-2 infection.

ATAGI strongly recommends that all eligible Australians receive their full course of vaccination.

The temporary vaccine exemption following infection is simply a recognition that there will be a period of natural immunity following infection.

Source
How Did You Hear About Us?
Please specify
Communication
I consent to receive SMS reminders, messages and emails*
- Yes
- No

Privacy and Terms
Please sign (using your finger or computer mouse) or place your electronic signature in the box below to confirm that you have read and agree to our “Terms & Conditions” and “Privacy Policy” and that all the information you have provided us in this form is true and correct to the best of your knowledge and belief.
Signature*
Now click “Finish” below to submit your request.

Step 1 of 16

Personal Details

Health Initiatives

Medical Information

IMPORTANT (Please read)

Medicare card

DVA card

Emergency Contact Information

Next of kin

Emergency contact

Your Health History

Social Activities

Which service do you require today?

Which service do you require today?

Quick Prescription Service

Absence From Work Certificate

Telehealth GP Appointment- 10 Mins

Telehealth GP Long Consult- 25 Mins

COVID-19 Vaccine Exemption Certificate

Telehealth Psychologist Appt - New Patient

Telehealth Psychologist Appt - 30 Mins

Telehealth Dietitian Appt - New Patient

Telehealth Dietitian Appt - 30 Mins

Absence From Work Certificate

Regarding Medicare Rebate

Please upload below a copy of your referral (Care Plan) from a GP through a Mental Health Care Plan (MHCP):

If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below:

Regarding Medicare Rebate

Please upload below a copy of your referral (Care Plan) from a GP through a Chronic Disease Management Plan (CDMP):

If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below:

Please upload below a copy of your COVID-19 (PCR test or RAT test) result :

Also, if applicable – please upload below a copy of evidence of the registration of your result with relevant state health department :

Source

Communication

Privacy and Terms

Now click “Finish” below to submit your request.

Bulk Billing Doctors’ availability-

IMPORTANT

Bulk Billing Policy for GP Services

Step 1 of 16

Personal Details

Health Initiatives

Medical Information

IMPORTANT (Please read)

Medicare card

DVA card

Emergency Contact Information

Next of kin

Emergency contact

Your Health History

Social Activities

Which service do you require today?

Which service do you require today?

Quick Prescription Service

Absence From Work Certificate

Telehealth GP Appointment- 10 Mins

Telehealth GP Long Consult- 25 Mins

COVID-19 Vaccine Exemption Certificate

Telehealth Psychologist Appt - New Patient

Telehealth Psychologist Appt - 30 Mins

Telehealth Dietitian Appt - New Patient

Telehealth Dietitian Appt - 30 Mins

Absence From Work Certificate

Regarding Medicare Rebate

Please upload below a copy of your referral (Care Plan) from a GP through a Mental Health Care Plan (MHCP):

If you have not already provided us with your Medicare card details, please enter your valid Medicare card details below:

Regarding Medicare Rebate

Please upload below a copy of your referral (Care Plan) from a GP through a Chronic Disease Management Plan (CDMP):

If you have not already provided us with your Medicare card details, please enter your valid Medicare card details below:

Please upload below a copy of your COVID-19 (PCR test or RAT test) result :

Also, if applicable – please upload below a copy of evidence of the registration of your result with relevant state health department :

Source

Communication

Privacy and Terms

Now click “Finish” below to submit your request.

Search

If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below:

If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below: