For Patients

E-Admission Form

  • Patient Details

  • Date Format: DD slash MM slash YYYY
  • Please enter a number from 0 to 100.
  • Medicare Number & Health Fund Details

  • Glenelg Day Surgery will conduct a health fund eligibility check and advise you of any health fund excess /co-payment that will be required to be paid on the day of admission.
  • Person financially responsible for Accounts (If self not-applicable)

  • Workcover/Third Party Accounts

  • Date Format: MM slash DD slash YYYY
  • Person for Notification/Emergency Contact

  • Declaration

    1. I certify that the information on this form is true and correct to the best of my knowledge. I accept full responsibility for accounts rendered by Glenelg Day Surgery including any shortfall in re-imbursement by my Health Fund and / or Workers Compensation gap following settlement by a Health Fund and/or Insurance Company.
    2. I certify that I have read the Rights and Responsibilities Brochure and Privacy Policy supplied by my admitting Doctor and agree to comply with the recommendations as indicated in the brochure.
    3. I consent to the collection and use of my personal information for the primary purpose of receiving medical care and I have been informed of my rights to access and correct my personal information.
    4. I understand that in the event of a power outage or other external/internal major event preventing my procedure from being performed my surgery may be cancelled.
    5. I understand that relatives/carers are not permitted to accompany me into the clinical area.
  • Enter your name here. By entering your name here you are agreeing the to declaration above.
  • Date Format: DD slash MM slash YYYY
Day Surgery 

Fully Accredited Day Surgery

Glenelg Day Surgery is a fully accredited private day surgical facility and member of the Australian Private Hospital Association. Glenelg Day Surgery specialises in plastic surgery, endovascular procedures, skin cancer surgery, oral & maxillofacial surgery, urological procedures, cosmetic surgery and assisted reproductive procedures.