I, the undersigned, understand and agree that: 

1. I am financially responsible for all charges related to the services provided by NerveSync Pty Ltd | Perth Migraine Centre, regardless of Medicare or private health insurance coverage. 

2. Payment is due in full at the time of service. Medicare rebates (if applicable) will be deposited directly into my nominated bank account. 3. For Workers' Compensation claims, I must pay the consultation fee in full after the appointment and seek reimbursement directly from my insurer. I acknowledge that reimbursement may not cover the full cost. 4. Privacy & Personal Data: 

• ● My personal information, including photographs/videos taken during consultations, will be collected and stored securely in compliance with privacy laws. 

• ● This media will only be used for medical documentation, treatment purposes, or with my additional written consent. 

• ● I may request access to or deletion of my records, subject to legal obligations. 

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Medicare Claims: 

I authorise NerveSync Pty Ltd | Perth Migraine Centre to release any information necessary to process my Medicare claims. 

Co-Payments and Gap Payments: 

I understand that any co-payments, gap payments, or non-covered services are due at the time of service, unless otherwise negotiated. 

Payment Options:

I understand that NerveSync Pty Ltd | Perth Migraine Centre provides several payment options and that it is my responsibility to discuss these options if I have financial concerns. 

Non-Payment: 

I understand that if my account becomes overdue, I may be charged collection fees, and/or legal fees incurred to collect the balance. I also understand that NerveSync Pty Ltd | Perth Migraine Centre may refuse future services due to non-payment. 

Cancellation Policy: 

I acknowledge that NerveSync Pty Ltd | Perth Migraine Centre has a 2 working day cancellation policy. If I cancel or reschedule my appointment within this period I may incur charges. 

I acknowledge NerveSync Pty Ltd | Perth Migraine Centre has a 7 day cancellation policy for any ad-hoc clinic appointments. If I cancel or reschedule within the 7 day period I will be charged $120. 

Acknowledgment and Consent: 

By signing below, I acknowledge that I have read, understand, and agree to the terms of this Patient Financial Consent Form. A Guardian should be signing onbehalf of the patient if the patient is less than 18 years of age or is medicallyunfit to give consent.