Please enter your details below or download it and complete it by hand. This form will be required for your initial consultation. If you would like the staff to contact you to arrange an appointment, please advise.
Personal information is sought from you in order to provide a proper assessment, diagnosis and treatment, and may be disclosed to other healthcare professionals involved in your care. Your medical file will be handled confidentially and with respect to your privacy. Central West Neurology & Neurosurgery is bound by the National Privacy Principles which set the standards by which we handle personal information collected from our patients.
You have a financial responsibility to cover the costs of any consultations or tests performed at these rooms. If an account remains unpaid, it will be referred to a Debt Recovery Agent and you will also be responsible for their collection fees.
We will use the information you have provided above to contact you.
In order for us to determine how to assist you, our reception staff may need to ask you questions about your health.
Please make sure you bring your referral with you to your consultation.