Sleep Screener Patient Consent

Patient Name

Title

First name

Middle name

Surname

Maiden name (if applicable)

Date of Birth (DD/MM/YYYY)

Patient pathway

Please select the pathway that took you to this service:

I scored 3 or above in the OSA Risk Assessment (STOPBANG) Questionnaire.Other

Please enter your OSA (STOPBANG) score

Please describe the pathway you took to this service

Patient Consent

I have read and understood the Limitations of this service

Yes

I have read and understood the Additional Information of this service

Yes

I understand that I may be liable up to the full wholesale value of the loaned equipment should I lose or break it

Yes

I am happy for Sleep WA to contact me to organise this service

Yes

There is a $170 up front cost for this service (Inclusive P&H)

I am aware of the up-front cost for this service

Yes

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.

Yes

Contact Information