Informed Financial Consent (Aesthetic Surgery)

By completing this form, you indicate that you intend to proceed with surgery with Dr Andre Safvat on the arranged date.

Patient name(Required)

Given name Family name

Patient Email(Required)

Planned surgery date(Required)

Fee information and consent(Required)

I have been given and understand the Fee Estimate for Dr Andre Safvat's services. I understand that any rebate amounts shown are approximate only and there will be an out of pocket amount for my procedure as indicated on the Fee estimate I received. I also understand rebate amounts shown on the estimate are approximate only.

I have been given a copy of the Fee Policy and I accept the fee terms outlined in the policy in relation to services provided by Dr Andre Safvat.

I understand that it is my responsibility to make payment two weeks prior to surgery and that failure to do so may result in the procedure being cancelled and deposit being forfeited.

I understand there may be variations to the fee once the surgery is undertaken and that I need to settle any outstanding amounts within 14 days of the surgery being completed.

I understand that it is my responsibility to check with my Private Health Insurer that I will be covered for the procedure (where applicable). If I am not covered for the procedure by my Insurer, I understand that I will be liable for extra costs with the hospital and other providers.

I understand that Ethique Plastic Surgery will endeavour to process my claim with Medicare and Health Insurance (where applicable) after my surgery. However, I also note that some health funds do not have this facility or at times are not available. If this is the case, I understand that it will be my responsibility to submit any claims to Medicare &/or Health Fund.

I understand that, in a small minority of cases, complications may occur and/or additional surgery may be required. I acknowledge that there may be extra fees and charges involved if this occurs and accept responsibility to pay for these additional fees. I also understand that if I do not have Private Health Insurance or I am not covered for the additional surgery, I may be liable for all costs associated with the additional surgery.

I understand that there may be additional fees from the anaesthetist, hospital, pathology etc. and that these will be my responsibility.

I understand and agree

Patient Signature – (please type name which will act as a manual signature).(Required)

First Last

Date Signed(Required)