Dr Simon Vun, FRACS

Specialist Vascular & Endovascular Surgeon

New Patient Registration Details

Please enter you personal and health details below.

Patient's First Name *

Patient's Last Name *

Preferred title

Preferred Name *

Patients Gender

Patients Date of Birth *

Mobile phone number *

Home phone number

Patient email address *

Patient's Home Address

Medicare and Insurance Details

Medicare card number

Medicare card IRN reference number (next to your name)

Medicare card expiry date

Do you have a concession or pension card? *

YesNo

Concession Card Number

Do you have a DVA or Veterans Card? *

YesNo

DVA card number *

DVA Card Type *

DVA Card Expiry date *

Do you hold Private Hospital Cover? *

YesNo

What level of Private Hospital Cover do you have? *

Gold/TopSilver+SilverBronze

Which private health insurance provider are you with? *

Please enter your private health insurance member number *

Do you currently work? *

YesNo

Previous/current Occupation or Trade *

GP Name *

GP Practice *

GP address

Street address

City

Postcode

Next of Kin Details

1. Next of kin full name *

1. Contact number *

1. Relationship to patient *

2. Next of kin full name

2. Contact number

2. Relationship to patient

Medical History

Please describe the your primary concern/symptoms/reason for referral. *

Do you have a history of heart disease? *

YesNo

Heart disease history *

Do you have diabetes? *

YesNo

Diabetes medication *

Diet controlledOral Medication/sInsulin and other medication/s

Do you take any blood thinners? *

YesNo

Eg. Aspirin, Cartia, Plavix, Clopidogrel, Brillinta, Ticagrelor, Warfarin, Marevan, Coumadin, Xarelto, Eliquis, Apixaban, Rivaroxaban, Pradaxa, Dabigatran etc.

Please state which blood thinners you are on *

Do you take any regular medications? *

YesNo

Medication list *

Have you ever had a blood clot or a deep vein thrombosis (DVT) before? *

YesNo

Details of previous blood clots or DVT *

Do you have any allergies? *

YesNo

Allergies List *

Do you smoke? *

YesNo

How long have you smoked for? *

Have you had any prior surgery? *

YesNo

List previous procedures/surgery *

Do you have a history of recurrent migraines?

YesNo

Do you have a known "hole in the heart" (also known as patent foramen ovale)?

YesNo

Have you seen any other specialists before? *

YesNo

Such as a cardiologist, neurologist, endocrinologist, vascular surgeon, rheumatologist, general surgeon, gastroenterologist, respiratory physician?

Please list the previous specialists you have seen previously: *

Do you have a copy of your referral, other supporting documentation or results?

YesNo

Please upload your referral or supporting documentation or results here

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Assignment and Consent

1. Private Patient Fees and Billing

As a private patient, payment is required on the day of your consultation.
Our fees are set at fair and reasonable levels but are higher than the Medicare Benefits Schedule (MBS) rebate.

Please note that private health insurance (Hospital Cover) does not cover outpatient services.

We accept Concession, Pension, and DVA card holders at reduced rates.

Consultation & Telehealth Fees (as of 31 August 2025)

Type & Item Number	Fee	Concession Rate	Medicare Rebate
Initial Consultation (In-person) – 104	$325	$280	$84.15
Review Consultation (In-person) – 105	$160	$140	$43.35
Initial Consultation (Telehealth – Video) – 91822	$325	$280	$84.15
Review Consultation (Telehealth) – 91823 or 91833	$160	$140	$43.35
Measurement of toe pressures using photoplethysmographic or Doppler techniques – 11610	$63.20	$63.20	$62.30

Procedures performed in private hospitals may incur additional gap payments. These will be discussed with you directly by Dr. Vun.

We kindly request at least 7 days’ notice if you need to reschedule or cancel an appointment.

⚠️ Missed or late-cancelled appointments without a medical reason may attract a fee of $150, which is not covered by Medicare.

2. Privacy Policy

Your Privacy

We collect and securely store your personal and medical information to provide high-quality healthcare. This includes your medical history, test results, and reports from other providers.

Your information is managed under the Privacy Act 1988 and the Australian Privacy Principles.

How Your Information May Be Used:

For your diagnosis, treatment, and ongoing healthcare
Administrative and billing purposes, including Medicare
Communication with your other health professionals (GPs, hospitals, diagnostic providers)
Compliance with legal or mandatory reporting (e.g., communicable diseases)
Professional accreditation, research, quality assessments, and clinical auditing

⚠️ We will not disclose your information to family members, spouses, or others (if you are over 16) without your signed consent.

You can help us maintain the accuracy of your information by advising the practice of any changes to your contact details, Medicare, health insurance, or medical information.

3. Digital Note-taking & Telehealth Support Tools

To ensure accurate clinical documentation, we use:

i-Scribe: A secure, AI-powered note-taking tool used by Dr. Vun.
- ISO 27001 accredited
- Fully encrypted
- Hosted on secure Australian-only servers
- No audio recordings are ever stored

You may withdraw consent for these tools at any time by informing Dr. Vun or staff.

4. Clinical Photography Consent

During your consultation or treatment, Dr. Vun may ask to take clinical photographs (e.g., of wounds, limbs, vascular conditions, or operative results) for the purposes of:

Documenting your medical condition in your record
Monitoring changes over time
Supporting diagnosis and treatment planning
Communication with other health professionals directly involved in your care (e.g., pathology, radiology, surgical teams)

These photographs are considered sensitive information under the Privacy Act 1988 and are protected accordingly.

You may withdraw your consent for photography at any time by notifying Dr. Vun or staff.

5. Patient Declaration and Authority

Your authority:

I understand and consent to the above.
I understand that I am not obliged to provide any information requested of me, but that failure to do so may compromise the quality of healthcare and treatment I receive.
I consent to the access of medical records and results held by other parties, such as radiology and pathology companies, and other hospitals (public or private) I may have attended, where access and review would be clinically relevant to my care.
I consent to the use of i-Scribe during my consultation and will notify Dr. Vun or his team if I wish to withdraw my consent.
I am aware of my right to access information collected about me, except where access might legitimately be withheld (for which I will be given an explanation), and that there may be costs involved. I understand that if my information is to be used for any purpose other than that set out above, my further consent will be obtained.
I certify that the information I have supplied is true and correct to the best of my knowledge.
I accept full responsibility for accounts rendered by Dr. Simon Vun Pty Ltd, including any shortfall in reimbursement by Medicare, Workers’ Compensation schemes, Health Funds, or insurance companies. I have been offered information relating to costs at this practice.
If I am uninsured while being treated as an inpatient or day patient in a private hospital facility, I accept personal responsibility for full payment of my specialist’s account.
I understand that total specialist fees for procedures and treatments cannot always be accurately quoted but only estimated in advance.
I have not altered the content of this form without verbally notifying the practice and treating practitioner, and I have obtained the practitioner’s signed agreement.

I have read and accepted the above.

Patient Signature *

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Date signed *

Name *

Complete to confirm human: *