Acute Disc Service Referral Criteria <Select next available or nominate a surgeon:>	
(Patients seen within 3 working days with the below criteria)	<Next available surgeon>	Next available surgeon	
√	Acute – sudden onset of pain (within 30 days)	<Nominated surgeon request (if available)>	Nominated surgeon request
(if available)	
Plus 	√   	Severe leg (Sciatica) or arm pain (Brachalgia)
	in a radiculopathic (nerve) pattern WITH proven
	nerve compression confirmed with MRI or CT		<Choose nominated surgeon>	
Or 	√	Leg weakness, arm weakness or numbness		Email acutedisc@nsiwa.com.au
for urgent booking	
Imaging scans conducted at:<Imaging scans conducted at:>	
<Image scan at SKG>	SKG	<Image scan at Perth Radiological Clinic>	Perth Radiological Clinic	<Image scan at Other>	Other	<Image scan conducted at other, name:>	

Patient details	
Patient name:	<PtFullName>	
Date of Birth:	<PtDoB>	Home Phone:	<PtPhoneH>	
Address:	<PtAddress>	
Email:	<PtEmail>	
Private Health Fund: 	<PtInsFund>	
Clinical comments:	<Clinical comments:>	
Current medications:	<SelectedRx>	
Patient history:	<SelectedPMH>	

 Acute Disc Service Referral Form		
Referrer details	
Referring doctor name:	<DrName>	
Practice:	<LocationName>	
Provider No:	<DrProviderNo>	
Signature: 		
Date:	<TodaysDate>	
Copy to:	<Copy to:>	
Contact	
P 1800 NEUROSPINE (1800 638 767)      F (08) 6147 8200 	E info@nsiwa.com.au (for general enquiries)	
			
Perth
Mount Medical Centre
Suite 7, Level 4
140 Mounts Bay Road
Perth WA 6000	Wembley
Suite 10, First Floor
178 Cambridge Street
Wembley WA 6014	Murdoch
Wexford Medical Centre
Suite 77, Level 4
3 Barry Marshall Parade
Murdoch WA 6150	
Sessional Consulting			
	Carine
St John of God Specialist Centre
Unit 1, 2 Gemstone Boulevard
Carine WA 6020	Mandurah
St John of God Mandurah
117 Anstruther Road
Mandurah WA 6210	
			
Vasse
Duchess Medical Centre
Suite 2
22 Napoleon Promenade
Vasse WA 6280	Albany
Amity Health
136 Lockyer Avenue
Albany WA 6330	Geraldton
St John of God Hospital
12 Hermitage Street
Geraldton WA 6530