M&B Form 004 - PreauthorisationUse this form to preauthorize appointment fees up to 6 days before your appointment date.Name(Required) First Last Email(Required) Use the email you you provided us with.This field is hidden when viewing the formFeeScheduleThis field is hidden when viewing the formInstructionsThis field is hidden when viewing the formNew Patient or Existing Patient? New ExistingNew patients include those that have not completed the intake and first and second psychiatrist appointments.New Patient Appointments(Required) Intake Appointment First Psychiatrist Appointment Second Psychiatrist AppointmentAppointment Type ADHD Assessment ASD Assessment Standard Appointment Extended Appointment Long AppointmentCheck your reminder for the correct Appointment FeeADHD Assessment Price: ASD Assessment Price: First Psychiatrist Appointment Price: Second Psychiatrist Appointment Price: Standard Appointment Price: Extended Appointment Price: Long Appointment Price: TMS Maintenance Price: TMS Bilateral Price: DNA - Initial Appointments Price: DNA - Follow-up Appointment Price: Pay Invoice Price: Date of Your Appointment(Required)DD slash MM slash YYYY Enter the date of your appointment. Preauthorization opens 6 days before the appointment date. If you cannot select your appointment date it is too early to preauthorize. Please do not attempt to preauthorize earlier than 6 days before your appointment.Total Payment OptionsTerms and Conditions(Required) I agree to the Terms and Conditions.For emergency care or in a life threatening situation, call 000 or present to your nearest emergency department. Crisis support is also available through Lifeline on 13 11 14 or the Mental Health Emergency Response Line on 1300 555 788. Further useful information can be found at https://www.yourhealthinmind.org. Do not use this enquiry form in a crisis. Responses may take up to 5 business days. By submitting this form you agree to these conditions.This field is hidden when viewing the formDate_Created MM slash DD slash YYYY
