Second Opinion Consent form

I hold an active hospital product for more than 12 months

YES

NO

I have a complex medical condition that isn't on the list of excluded conditions and have had at least one consultation with a specialist.

YES

NO

You might not be eligible for this service. For more information, call us on 13 13 34 

The information you provide will be sent to HCF’s wellbeing team and, if all eligibility criteria are met, also to MedHealth.  

Current HCF Membership No.

What’s your title?

Title Mr Mrs Miss Ms Dr

What's your first name

What’s your last name?

What’s your date of birth?

What's your best Australian mobile or landline phone number?

• Don't include the Country code (+61)
• Your number must start with a "0"

Please select your preferred time to call

Time to call 8.30 AM to 10.00 AM 10.00 AM to 12.00 PM 12.00 PM to 02.00 PM 02.00 PM to 05.00 PM

By completing this form I consent for my details to be sent to HCF and MedHealth so I can be contacted about the second opinion service.

Submit