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Sleep Screener Patient Consent
Maiden name (if applicable)
Date of Birth (DD/MM/YYYY)
Please select the pathway that took you to this service:
I scored 3 or above in the OSA Risk Assessment (STOPBANG) Questionnaire.
Please enter your OSA (STOPBANG) score
Please describe the pathway you took to this service
I have read and understood the Limitations of this service
I have read and understood the Additional Information of this service
I understand that I may be liable up to the full wholesale value of the loaned equipment should I lose or break it
I am happy for Sleep WA to contact me to organise this service
There is a $170 up front cost for this service (Inclusive P&H)
I am aware of the up-front cost for this service
I am aware that I also need to submit the 'Sleep WA Sleep Questionnaire' and the 'New Patient Registration Form' before I can proceed with this service.
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