Confidential Patient Questionnaire

The following information is requested to ensure that you are correctly identified in our records, to save you time and to assist us in giving you the best possible care. All of the information which you provide will be treated as being strictly confidential. This practice conforms with the National Privacy Principles and a copy of our Privacy Policy is available upon request.

Please complete and submit the below form. Alternatively, you can download and print the Patient Questionnaire, which can be returned via email to [email protected] or faxed to 07 5503 2488.

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Patient Details

DD/MM/YYYY

Doctor Details

Medicare Details

War Veteran Details

The aim in this practice is for patients to be well-informed about their condition, and about any recommendations made for treatment. It is important therefore for you to say at the time if there is anything you do not understand, or about which you wish to know more. An exception to this occurs if you are referred for insurance or medico-legal assessment by a third party, when we are not at liberty to discuss your diagnosis or management.

Please note also that if you are given a follow-up appointment, it is important to attend. Otherwise, you may fail to receive important test results or advice. We do not and cannot take responsibility for your neurological care if you do not keep appointments which are made for you or do not follow the advice we give you.

Our fees for electroencephalography (EEG) and nerve-conduction studies/EMG studies and the related clinical consultation are routinely bulk-billed. Any other tests will be quoted by the receptionist.

PATIENT ACKNOWLEDGEMENT AND CONSENT


I have read the information set out on this form. I agree with this information and hereby consent to my medical details including any medical reports being released to my referring medical practitioner(s) and to any other medical practitioner(s) who treats me now or in the future including any other medical practitioner to whom Prof. Corbett refers me. My consent is based upon the understanding that such release is intended to be in the best interest of my health. If my referral has been for the purposes of Workcover or Medico-legal assessment, then I consent to the release of any such details or reports to the insurer or my solicitors at their request or to any other party with my solicitors consent.

I hereby give authorisation for any of my past medical records to be released to Professor John Corbett. To the best of my knowledge and belief all of the information I have provided is true and correct.