New Client Information Download PDF Form "*" indicates required fields Contact DetailsClient Name* First Last Date of Birth* DD slash MM slash YYYY Address* Street Address Address Line 2 Town / Suburb State Postcode Email* Phone Number* Medicare Number Ref Personal InformationWhich of the following best describes you? ( please tick any that apply )* I have been referred for a diagnostic Sleep Study by my GP or other health professional. I have been prescribed CPAP therapy by my GP or other health professional. I am an existing CPAP user. I am interested in improving my sleep quality / seeking information. Other Other ( please specify )* Have you had a Home-Based Sleep Sudy in the past 12 months? Yes No Referring Doctor ( if applicable )Doctor's Name Doctor's Address Street Address Address Line 2 Town / Suburb State Postcode Privacy StatementPrivacy Statement / Consent* I consent to the following privacy statementI CONSENT to the disclosure and dissemination of my personal health information to my nominated carers, including the referring Doctor, Supervising/Reporting technician, Sleep technician, Sleep clinician and any Administrative personnel nominated by Gawler Sleep Clinic, for the sole purpose of diagnosing and/or treatment of my suspected/diagnosed Sleep Disorder.SignatureToday's Date DD slash MM slash YYYY
