New Patient Form

New Patients: Please complete this form, and we will contact you to arrange an appointment
Existing Patients: Please call or email to arrange your next appointment

First Name

Last Name

Date of Birth

Gender

Male

Female

Home Address

Phone

Medicare Number

Position On Card

Referring Doctor

Please upload a photo of your referral (if you have one)

Photo

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Please upload a PDF of your referral (if you have one)

PDF

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Emergency Contact / Next of Kin - Name

Emergency Contact / Next of Kin - Phone

Emergency Contact / Next of Kin - Email

Who are you seeking to make an appointment with?

Dr Rowena Mobbs. Specialist in cognitive disorders including dementia, Alzheimer's disease, CTE, concussion, headaches, migraine, and Botox therapy.

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.

Either. For general neurology

Who will pay the doctor's fee?

I will pay the doctor's fee before or immediately after the appointment.

Defence (ADF, DVA)

Terms and Conditions

1) I agree to pay the doctor's fee before or immediately after consultation (no bulk billing). If covered by CTP, Workers' Compensation, iCare, or other insurance, I accept responsibility for seeking reimbursement from my insurer if eligible.  2) Harbour Neurology utilises ClinicToCloud's Patient Portal. We encourage patients to use this portal to maintain their personal information and access letters and invoices.     3) I authorise Harbour Neurology to document my medical history, conditions, and management.     4) I authorise Harbour Neurology to obtain relevant information from other medical practitioners, healthcare providers, and My Health Record.     5) I authorise Harbour Neurology to share relevant information with other medical practitioners, healthcare providers and My Health Record.

I agree to the terms & conditions

Thank you! We will be in contact shortly

New Patients: Please complete this form, and we will contact you to arrange an appointment
Existing Patients: Please call or email to arrange your next appointment

Phone: (02) 9900 5500 Email:@harbourneurology.com.au

Level 6/53 Walker Street
North Sydney 2060

EDI: HealthLink (harbourn)
or Medical Objects

New Patients: Please complete this form, and we will contact you to arrange an appointment Existing Patients: Please call or email to arrange your next appointment

New Patients: Please complete this form, and we will contact you to arrange an appointment
Existing Patients: Please call or email to arrange your next appointment