Contact Us - Wickham Terrace Anaesthesia

DO YOU HAVE ANY QUESTIONS? GET IN TOUCH WITH US TO FIND OUT MORE.

To assist with your enquiry please submit the following form. We will endeavour to respond to you by the next business day. If the matter is urgent, please contact our office via phone.

Office hours: 8:00am – 5:00pm | Monday – Friday (except public holidays)

Title*
Name*
First Last
Date of Birth*

Day
Month
Year
Street Address*
City/Suburb*
State/Territory*
Postcode*
Country*
Contact Number*
Email Address*
Do you have Private Health Insurance that will cover you for the procedure?*
- Yes
- No
Name of Health Fund*
Policy Number*
Do you have Medicare?*
- Yes
- No
Medicare Number*
IRN/Card Position*
*number next to the name on your Medicare Card
Date Of Surgery*
DD slash MM slash YYYY
Select Anaesthetist*
Surgeon Name*
First Last
Hospital*
Description of Procedure*
Message
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Consent*
I consent to providing my health information to Wickham Terrace Anaesthesia and understand my health and personal information will be used by my Anaesthetist to manage my healthcare in accordance with the Wickham Terrace Anaesthesia Privacy Policy
*We require you to consent to providing your health information to provide you with anaesthetic information. Please contact our office to discuss this further if you do not consent (07) 3831 0383
View our Privacy Policy here.
Email Consent*
I consent to Wickham Terrace Anaesthesia emailing me a quotation on behalf of my anaesthetist and any other anaesthetic information that may be necessary
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