NEW PATIENT REGISTRATION FORM

If you are already a Pacific Sleep client, please do NOT complete this form. New referrals for existing clients can be sent to bookings@pacificsleep.com.au

General Information

Patient first name *

Patient surname *

Date of birth

Email Address

Mobile phone

Home phone

Address

Street address

City

State

Postcode

Medicare Card Number

Medicare IRN (individual reference no.)

Medicare Expiry Date

DVA File No (if applicable)

How did you hear about us?

Please upload your referral or any other relevant documents here (if you have them)

Browse

Emergency Contact / Next of Kin / Carer / Support Person

Name *

Phone *

Next of Kin's Email

Emergency Contact's relationship to you

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

Pension/Concession Card No

Do you have a drivers licence?

Are you a commercial driver?

Health Information

General Practitioner's Name

Referring Doctor's Name (if not your GP)

Do you have NDIS support?

If yes, what type of funding?

NDIS plan dates?

Do you have a Home Care Package?

Does an organisation manage it?

Organisation Contact Person

Contact person phone no

Contact person email

Who is financially responsible for this account?

Email for invoices (if not the same as client)

Medical History

1. Have you had a sleep study in the last 12 months? (IMPORTANT! Medicare will only cover ONE approved sleep study in a calendar year. If you have had a sleep study with another provider in the past 12 months, we cannot claim Medicare benefits for you, and you will need to pay for the test yourself). *

YesNo

2. Do you snore?

YesNo

3. Do you have chronic nasal congestion?

YesNo

4. Do you wake with a dry or sore throat?

YesNo

5. Do you wake up with a headache?

YesNo

6. Do you wake up with an unclear/foggy head?

YesNo

7. Do you have a poor memory?

YesNo

8. Do you go to the bathroom at night?

YesNo

8a. If yes, how many times?

OnceTwiceMore than three times

9. Do you wake up without getting out of bed at night?

YesNo

10. Do you have Diabetes Type 2?

YesNo

11. Do you have High Blood Pressure?

YesNo

12. Have you had a stroke or TIA (mini stroke)?

YesNo

13. Do you have gastric reflux or heartburn at night?

YesNo

14. Have you had a heart attack or any heart surgery?

YesNo

16. Do you smoke?

YesNoI used to smoke

17. Do you have restless legs syndrome (RLS)?

YesNo

18. Do you have medically diagnosed depression?

YesNo

Any other comments?

Height (cm)

Weight (kg)

BMI (if you know it)

Your normal time to bed

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Use the following scale to choose the most appropriate number for each situation :

0 = Would never doze

1 = Slight chance of dozing

2 = Moderate chance of dozing

3 = High chance of dozing

Sitting and reading

Watching TV

Lying down to rest in the afternoon when circumstances permit

Sitting inactive in a public place

Sitting and talking to someone

As a passenger in a car for an hour without a break

In a car, while stopping for a few minutes in the traffic

Sitting quietly after lunch (without the consumption of alcohol)

ESS Total Score

STOP BANG Questionnaire

Snoring? Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?

YesNo

Tired? Do you often feel Tired, Fatigued, or Sleepy during the day (such as falling asleep during driving or talking to someone)?

YesNo

Observed? Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?

YesNoUnsure

Pressure? Do you have or are you being treated for High Blood Pressure?

YesNo

BMI? Body Mass Index more than 35 kg/m2?

YesNo

Age? Are you older than 50?

YesNo

Neck Size large? (For male, shirt collar 43cm or more? For female, 41 cm or more?)

YesNoUnsure

Gender = Male?

YesNo

STOP BANG Score Total

Medicare Claims and Payment Information

I understand that Pacific Sleep and its providing doctors will, where possible and in accordance with Medicare rules and conditions, submit claims to Medicare on my behalf and with my consent. I understand that not all claims will be accepted by Medicare, and where claims cannot be processed, I will receive an invoice and be responsible for payment for the services received. *

I understand that not all services provided by Pacific Sleep and its providing doctors are covered by Medicare. I understand that I will be informed of the cost and be responsible for payment of invoices for these products and services on the day of consultation. *

I understand that Pacific Sleep may loan me equipment for the purpose of my medical test. I agree to take proper care of this equipment, and return it clean and undamaged on the day immediately after my test. I understand that I will be responsible for the full cost of any lost or broken equipment. *

Privacy

I hereby acknowledge that I am aware of my right to access my personal information. *

I hereby acknowledge that I am aware of my right to withdraw my consent at any time. *

I understand that my provider must comply with relevant privacy laws and I will contact the organisation immediately if I feel that these laws have been breached. *

I understand why certain information about me may need to be provided to other service providers in order to coordinate the best support for me. *

Consent

I confirm that above information I have provided is true, complete and accurate. *

I consent to receiving emails from Pacific Sleep about new products, services, special offers and more.

I agree to the assignment of the Medicare benefit directly to the health professional where the provider submits claims on my behalf. *

Optional question: How did you hear about Pacific Sleep? (dropdown list)

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