Dr Gurbir Kaur

Specialist Pain Medicine Physician

MBBS, DNB Anesthesiology, FFPMANZCA

Personal Information

Title *

First Name *

Last Name *

Date of birth *

Phone no *

Email Address *

Postal address *

State *

Post Code *

Emergency Contact Name, Relationship *

Emergency Contact Number *

Country of Birth *

Languages spoken *

Interpreter required

NoYes

Referrer Details

Name of Referring doctor or Specialist *

General Practitioner's name *

GP practice address

Practice nameStreet address

City

State

Postcode

Which consulting location would you like to visit? *

Kogarah - Suite 1, Ground Floor/19 Kensington St, Kogarah NSW 2217Gledswood Hills - Level 2, Suite 19/13 Digitaria Dr, Gledswood Hills NSW 2557

How did you hear about us ? *

Billing Address

Do you have medicare card ? *

Yes No

Medicare Number *

Reference *

Expiry *

Health Fund *

Yes No

Health Fund

Member number

Do you have a pension card ? *

Yes No

Pension card no.

Expiry date

Does this relate to a NSW WorkCover claim? *

YesNo

Does this relate to any other Third Party Claim? *

YesNo

Does this relate to an application of NDIS/ and total permanent disability? *

YesNo

Dr Kaur does not see patients for application of NDIS and total permanent disability

Is this appointment solely for opioid endorsement or opioid prescribing? *

YesNo

Dr Kaur is an Interventional Pain Specialist and does not see patients for opioid endorsements alone.

Is this for Cannabis endorsement or prescribing? *

YesNo

Dr Kaur does not prescribe or endorse medicinal cannabis.

Informed Financial Consent

I understand that Dr Kaur is a private biling practitioner and will not Bulk Bill.

A non-refundable pre-payment of $100 must be made to secure the appointment. The remaining balance to be paid on the day of consultation.

Initial specialist consult (in-person or telehealth) fees $465, Medicare rebate $148.35 and out-of-pocket $316.65.

Subsequent consult ( in-person or telehealth) fees $230, Medicare rebate of $74.25 and out-of-pocket cost $155.75.

Fees for pensioners: Inital appointment $385, subsequent appointment $190

The above fees do not include any injections or treatments on the day.

For procedures performed in hospital, there will be out-of-pocket fees. These will include a 'gap' payment for both the procedure and anaesthetic. A hospital excess payment to your private health fund may be required. Depending on your private health fund, you may have larger out-of-pocket expenses. Please advise our staff if you are insured with NIB or GU Health.

I agree *

Cancellation Policy

Cancellation Fees:

If appointments are cancelled, rescheduled within 48 hours of the scheduled appointment or patients do not attend, a $100 cancellation fee will be charged. No further appointments will be made until the fee is paid.

If the patient is a Workcover/DVA or ADF patient, this cancellation fee will be paid by the patient personally and not covered by the third party.

SMS Confirmations

We will send an SMS reminder 7 days and again at 4 days before your appointment.

Please reply “Y” if you can attend or “N” if you wish to cancel/reschedule.

All appointments need to be confirmed within 48 hours of your appointment.

If you have not replied to the confirmation SMS and/or not completed this form we will assume you are not attending and the appointment will be cancelled.

I understand and agree to the terms above in relation to cancelled appointments and confirming appointments. *

Additional information

Please upload your GP/Specialist referral and imaging results here. We also require your medical & surgical details and Specialist letters . *

Browse

Your appointment will not be confirmed unless GP/Specialist referral is attached.

Patient Acknowledgement

I give my consent for my treating physician/provider to collect, use and disclose my personal information to medical staff and allied health potentially involved in my treatment as outlined in the Privacy Act 1988 and national privacy principles. This can involve discussing my medical history, diagnoses, and care preferences at a case conference, which may be billed to Medicare.

If I would like to know more or if there are certain aspects of my medical history or personal information that I would like withheld I will discuss this with my physician/provider during my appointment.

I agree *

I agree to the collection and confidentiality of my personal information in my electronic file. I allow the practice to send me reminders via post, email, telephone or SMS for appointments or health matters.

I agree *

Signature *

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If you have any queries, please do not hesitate to email us on referrals4gkaur@gmail.com or call us on 1300 852 514.