Xeomin® PBS Program

WSPOIC Pharmacy 

Westmead Specialist Centre

Level 2, 16-18 Mons Road 

Westmead, NSW, 2145

Phone: 02 8837 9850   Fax: 02 8837 9846

email: xeomin@ramsayhealth.com.au

Patient Consent and Co-Payment Form

Botulinum Toxin PBS Supply

Clinic Information

Clinic Name *

Clinic Email *

Patient First Name *

Patient Surname *

Patient to complete consent form on tablet provided  OR

Patient to complete consent form on their device

Enter Patients Email only if completing on patients own device

Patient Consent and Co-Payment Form.

S100 - Botulinum Toxin PBS Supply

Patient Information

Patient Consent and Co-Payment Form.

S100 - Botulinum Toxin PBS Supply.

Patient Information.

First Name *

Surname *

Patient Phone Number *

Date Of Birth *

Medicare Card Number *

Concession or DVA number *

Safety Net (SN) or (CN) card number *

Patient Street Address *

City *

State *NSWACTQLDVICSAWATASNT

Postcode *

First Name *

Surname *

Patient Phone Number *

Date Of Birth *

Medicare Card Number *

Concession or DVA number *

Safety Net (SN) or (CN) card number *

Patient Street Address *

City *

State *NSWACTQLDVICSAWATASNT

Postcode *

Patient Consent

Patient Consent.

I acknowledge that I have been made aware of the requirement to make a co-payment for each Botulinum Toxin treatment to Ramsay Pharmacy and accept the relevant charge. As of January 2024, the current co-payment amount applicable to a concessional patient is $7.70 and for general patients is $31.60. These figures are reviewed and indexed annually by the Government.

I consent to Ramsay Pharmacy accessing my relevant Medicare details from Medicare Australia wherever necessary to support this supply
*

Patient unable to sign - signed on patients behalf by

 

Patient Signature *

Clear

Date *

I acknowledge that I have been made aware of the requirement to make a co-payment for each Botulinum Toxin treatment to Ramsay Pharmacy and accept the relevant charge. As of January 2024, the current co-payment amount applicable to a concessional patient is $7.70 and for general patients is $31.60. These figures are reviewed and indexed annually by the Government.

I consent to Ramsay Pharmacy accessing my relevant Medicare details from Medicare Australia wherever necessary to support this supply
*

Patient unable to sign - signed on patients behalf by

 

Patient Signature *

Clear

Date *

Treatment Information

Treatment Date *

Xeomin - No vials used

E-Script sent to pharmacyuser.wso@ramsayhealth.com.au       OR

Script sent to Ramsay using XEOMIN PBS Program - REPLY PAID Envelope

Further Notes

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