Appointments

Below is an appointment request form. Please fill in the form and our staff will get in touch with you within 24 hours during weekdays to organise your appointment.

To enable us to assess the urgency of your problem and offer you a suitable appointment, please answer the questions as accurately as possible:

Name:

DOB:

Best contact number:

Email:

Status:

Worker's Compensation
CTP/other 3rd party claim
Medicare only
Private Health Insurance
Overseas visitor

Service Needed:

Neurosurgery & Spine Surgery
Pain Medicine
Occupational Medicine
Spine Physiotherapy
Spine Physician Clinic

Appointment Type:

Initial
Follow up
Telehealth

Problem:

Neck
Back
Brain
Peripheral Nerve
Other

Chronicity: When did your symptoms start?

What is your MAIN/MOST SEVERE symptom at the moment:

Back pain
Neck pain
Leg pain
Arm pain
Numbness/pins & needles in arms or legs
Weakness in arms or legs
Headaches

Since when have you had your MAIN/MOST SEVERE symptom?

Severity of symptoms:

Symptoms are moderate (come and go)
Symptoms are quite severe (often in a lot of pain)
Symptoms are unmanageable and disabling (severely affecting quality of life)

Treatments previously undertaken:

physiotherapy
spinal/cortisone injections
chiropractic
massage therapy
acupuncture
pain killers (Neurofen, Panadol etc)
opiate analgesics (Endone, Oxycontin)
surgery

Investigations undertaken:

X-Ray
CT scan
MRI scan
Neurophysiological studies
Nerve conduction studies
Bone scan
Other

Attach clinical documents (Referral letter, CT/MRI/XRAY reports, etc):

Acceptable file types: doc,docx,pdf,txt,gif,jpg,jpeg,png.
Maximum file size: 1mb.

Notes:

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