FINANCIAL CONSENT TO TREATMENT WITH MS-2STEP (Mifepristone , misoprostol)
First Name
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Last Name
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Date of birth
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Date of Procedure
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Doctor
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Note if you have not had a dating US or pathology you will require a pre MTOP consultation before Doctor can prescribe the medication required to continue with termination
You must have recent pathology confirmation of pregnancy if the consultation is to go ahead
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Yes I have and can proceed with appointment
No I have yet to
Which pathology company did you attend?
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QML
4Cyte
Sullivan Nicolaides Pathology
Other
Do you have copies of these reports?
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Have you had a dating Ultrasound
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Yes I have and can proceed with appointment
No I have yet to
Which Radiology company did you attend?
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Haven
QLD Xray
South Coast Radiology
Gold Coast Radiology
Other
Do you have copies of these reports?
Browse
Financial Consent
Type of Appointment
Fee
Medicare Rebate
1. Pre Consult with Doctor for investigations
$105.00
Eligible Medicare Card Holders $42.85
2. Medical Termination Consultation
$400.00
No medicare rebate applicable
I have read and understood the finances that are related to this procedure
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I have further questions regarding financial section, I would like a specialist admin team member to discuss this with me further prior to my procedure date:
Patients name
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Date
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Signature
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