General anaesthetic: medical form and booking consent

General Anaesthesia Consent form for Booking Deposit

PLEASE READ ALL INFORMATION CAREFULLY

As discussed, I agree that the proposed treatment be undertaken under General Anaesthesia. I understand the specialists at Tooth Town operate in a hospital/day surgery setting, as it provides the safest and least traumatic delivery of treatment.

In order to secure a booking for a general anaesthetic procedure, a $300.00 booking deposit to be paid within 24 hours of making the booking. This amount will be deducted from the outstanding Dental fees.

I understand that there are THREE fees associated with a general anaesthetic booking: the Hospital admission fee, the Anaesthetist fee and Tooth Town's Dental Fees, as stated below.

I understand once making the booking, I will be notified of my admission and surgery times at least two days prior to the surgery. I understand that my child's admission time is dependent on age and medical condition, and is up to the anaesthetist's discretion to make changes.

I understand that the Anaesthetic fee can be upwards of $1,250 for the procedure, which is paid directly to the anaesthetist rooms when invoiced. If I have health insurance, I understand that the rebate paid can differ and is dependent on my health fund and my level of cover.

I understand that the Hospital Admission fee is to be paid directly to the hospital in FULL and it is my responsibility to process the claim and receive the rebate, after the procedure. I understand that the Hospital Admission fee can be upwards of $1,350. I understand that if I have a health fund, the rebate may differ dependent on my health fund and my level of cover.

I understand that the Tooth Town Dental Fees are outlined in my child's treatment plan and they must be paid in full TWO WEEKS prior to the allocated surgery date. I understand that I am required to claim my rebate myself once all outstanding treatment fees have been paid, AFTER treatment has been completed, and I have received the final invoice.

I understand that I MUST pay the $300.00 booking deposit, if my booking date is over 3 weeks away, in order to secure my booking. I understand this will be deducted from the final dental fees I am required to pay. If the procedure is in less than three weeks the full value of the treatment plan is to be paid upon booking.