New Patient Registration

Harbour Neurology
Level 6/53 Walker Street
North Sydney 2060
Phone: 02 9900 5500
Reception@HarbourNeurology.com.au

First Name *

Middle Name(s)

Last Name *

Date of Birth *

Gender *

MaleFemaleOther

Mobile Phone Number *

Email Address *

Residential Address *

Street address *

Suburb *

Postcode *

Do you have a Medicare Card? *

YesNo: Overseas residentNo: ADF/DVA

Medicare Number (Enter '0000 00000 0' if not applicable) *Please enter numbers only - no spaces, dashes, or commas.

Medicare: Position on Card *

Next of Kin/Emergency Contact

Next of Kin: Name

Next of Kin: Email

Next of Kin: Phone

Appointment Required

Are you seeking to make an appointment for *

Neurology [Required prior to your initial appointment with A/Prof Mobbs, Dr Fois, or Dr Lahoria]Electroencephalogram (EEG)Nerve Conduction Study (NCS) [Peripheral neuropathy: Neuropathic or nerve pain disease or dysfunction of the nerves, Ulnar neuropathy: Neuropathic or nerve pain, disease or dysfunction of the ulnar nerve in the arm, Carpal tunnel syndrome: Neuropathic or nerve pain, disease or dysfunction of the median nerve in the hand]Neuropsychology [Required prior to 4 - 6 hours consultations for Neuropsychological report by Professor Batchelor, Dr Lye, or Dr Watt]

Which Neurologist *

A/Professor Rowena Mobbs: Specialist in cognitive disorders including memory issues, dementia, Lewy Body disease, Alzheimer's disease, CTE, EEG, concussion, headaches, hyperhidrosis, migraine, Botox therapy, elite and professional sports, NDIS, CTP and Workers' Compensation claims.Dr Alex Fois: Specialist in movement disorders including Parkinson's disease, Lewy body disease, epilepsy, motor neurone disease, multiple sclerosis, neuropathy, tremor, dystonia, restless legs syndrome and Tourette syndrome.

Neuropsychologist *

A/Professor Jenny BatchelorDr Tanya LyeDr Sharon WattNext available

Referral

Do you have a referral? *

Yes, from GPYes, from SpecialistNo

Name of Referring Doctor *

Please upload your referral, previous scans etc.

Browse

Please press the shift button and select as many documents as required.

CTP/Motor Vehicle Injury

Does your appointment relate to a Motor Vehicle Accident or CTP claim? *

NoYes

CTP Insurer? *

Claim Number? *

Workers Compensation/Work Place Injury

Does your appointment relate to a Work Injury or Workers' Compensation claim? *

NoYes

Name of your Workers' Compensation Insurer? *

Claim Number? *

Australian Defence Forces

ADF: Are you currently serving in the Australian Defence Force? *

NoYes

Defence Approval Number (DAN)? *

Eligible Person ID (EPID)? *

Department of Veterans Affairs

DVA: Do you have a Veteran Gold Card or Veteran White Card? *

NoYes

DVA Card Number? *

DVA Card Colour? *

GoldWhite

Terms and Conditions

Privacy

We may receive, record and share your medical history, conditions and management with other medical practitioners, healthcare providers, hospitals, and MyHealthRecord. Unless you advise us otherwise, we may share your medical information with your family, caregivers, insurers and legal representatives. We will not share your medical information with others without your consent, except as the law requires.
Harbour Neurology communicates with you via email and/or SMS. Email communication is unencrypted and therefore carries some privacy risks. If you do not wish to receive such communication, please call Reception on 02 9900 5500.

I agree to the terms and conditions *

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