Paediatric Sleep Study Consent & contract

Sleep Study Consent & Contract

Date of child's booked sleep study(Required)

If you do not have a sleep study booked at Newcastle Health Enterprise, please do not complete this form

Patient Details

Patient Name(Required)

First Last

Patient DOB(Required)

Patient Address(Required)

Street Address Suburb State Postcode Country

Name of person filling out this form(Required)

First Last

Relationship to patient(Required)

Contact number(Required)

Patient Medicare Number(Required)

Patient Medicare IRN (1 digit next to patient's name)(Required)

Medicare Expiry Month/Year(Required)

Account Holder Details

For Medicare Claiming

I am(Required)

The parent

The legal guardian or carer

Other

Please define other

Parent/guardian title(Required)

Parent/Guardian Date of Birth(Required)

Parent/Guardian Medicare Number(Required)

Parent/Guardian Medicare IRN (1 digit next to parent's name)(Required)

I live at the same address as the patient(Required)

Yes

Address

Street Address City State Post Code Country

Medicare Rebate(Required)

I understand that the account holder listed will receive the Medicare rebate for any appointments and surgeries, and it is MY responsibility to update Newcastle Health Enterprise of any changes to the account holder

Relevant medical history

My child (the patient) goes to sleep at(Required)

My child (the patient) wakes up at(Required)

My child's height (cm)(Required)

My child's weight (kg)(Required)

Does your child have any learning, developmental, or behavioral needs we should be aware of to provide the best care? (Examples may include ADHD, autism, sensory sensitivities, or other conditions)(Required)

Yes

Please provide detail of sensory/learning/developmental needs

Sleep study contract and consent

Sleep study set up(Required)

To the best of my knowledge, my child will be able to tolerate the application of the sleep study device (approx. 45 minutes) and keep the device in place overnight

Contract & Consent(Required)

1. Hire of Equipment

1.1 Provider agrees to hire the Equipment to Hirer, and Hirer agrees to hire the Equipment from Provider, subject to the terms of this Agreement.

1.2 Hirer acknowledges receipt of the Equipment in good working condition and agrees to inspect and notify Provider of any faults immediately.

2. Use and Care

2.1 Hirer shall use the Equipment solely for its intended purpose (overnight home sleep study on child) and in accordance with all operating instructions and safety guidelines provided by the Provider.

2.2 Hirer shall keep the Equipment in their possession and control and shall ensure the Equipment is stored securely and protected from damage, theft, and unauthorized use.

3. Deposit and Charges

3.1 Hirer authorizes Provider to place a hold of AUD $1.00 on Hirer’s credit card.

3.2 If the Equipment is not returned by the due return date, Provider will charge the Deposit in full as liquidated damages for non‑return.

3.3 If the Equipment is returned damaged, Provider will charge the Hirer’s credit card for the cost of repair or replacement, at Provider’s sole discretion.

3.4 Provider will release any uncharged portion of the Deposit within 14 business days after satisfactory return and inspection of the Equipment.

4. Loss, Damage, Theft or Destruction

4.1 Hirer bears full responsibility for loss, theft, or destruction of the Equipment during the Hire Period.

4.2 In the event of loss, theft, or destruction, Hirer must notify Provider immediately and will be liable to pay the full replacement cost of the machine.

5. Data Handling and Privacy

5.1 Hirer acknowledges and agrees that the de-identified sleep study data collected during the use of the equipment will be securely transmitted to an offsite sleep technician for analysis.

5.2 All data will be transmitted via secure channels in accordance with relevant privacy and data protection regulations.

5.3 No personal identifiers will be shared with the offsite technician.

5.4 Provider will handle all personal and health information in compliance with applicable privacy laws and standards.

6. Allergic Reactions

6.1 If your child experiences an allergic reaction to the sensors or the surgical tape used during the sleep study, please remove the affected components immediately.

6.2 Administer an appropriate antihistamine as required.

6.3 If symptoms persist or worsen, seek medical attention promptly.

7. Study Completion and Valid Results

7.1 Hirer acknowledges that the sleep study requires the Equipment to remain correctly fitted and worn by the child overnight in order to obtain sufficient data for clinical analysis.

7.2 If the Equipment is removed, tampered with, or not worn for a sufficient period overnight resulting in an incomplete or unusable study, the Provider may be unable to generate a valid sleep study report.

7.3 In such circumstances, the consultation and sleep study fee will be considered forfeited and a repeat study may be required at the Hirer’s expense.

7.4 Where repeated intolerance to the Equipment occurs, the Provider may recommend an alternative form of sleep study, including an in-hospital study where appropriate.

I agree to the above terms and conditions, and consent to my child being fitted with the sleep study device

Parent/guardian signature(Required)

Todays Date(Required)

Newcastle Health Enterprise
218 Pacific Hwy
CHARLESTOWN NSW 2290

Entrance via Pearson St Mall

P: 02 4955 8044

F: 02 4955 8055

admin@newcastlehealthenterprise.com.au