Quote Request – Herston Private Hospital

Hospital Quote Request

This contact form should be used for quote request and will be checked during business hours. Please DO NOT use this form if you are experiencing a medical emergency. Instead, please call 000 for urgent care. Please allow 48 hours to process quote request.

Parent/Guardian

Patient(Required)

Patient Date of Birth(Required)

Patient Gender

Date of Procedure (if known)

Item Numbers / Procedure Details

Time / Duration (as per Surgeons rooms)

Surgeon

Expected Stay(Required)

Overnight Stay

Same Day Procedure

Health Fund (if applicable)

Membership Number

Email(Required)

Phone(Required)

Additional Notes