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Sleep Screener Patient Consent
Patient Name
Title
Please select...
Mr.
Mrs.
Ms.
Miss.
Master.
Dr.
Prof.
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