Acute Disc Service Referral Form	

Dr Greg Cunningham, Spine Surgeon
Dr Michael Kern, Neurosurgeon
Dr Andrew Miles, Neurosurgeon 
Dr Paul Taylor, Spine Surgeon	For Privately Insured
& Workers Compensation Patients	

Services requested:	

Acute Disc Service Referral Criteria	

(Patients seen within 3 working days with the below criteria)	

	
Acute – sudden onset of pain (within 30 days)	

Plus	
	
Severe leg (Sciatica) or arm pain (Brachalgia) 
in a radiculopathic (nerve) pattern WITH proven nerve compression confirmed with MRI or CT	

Or	
	
Leg weakness, arm weakness or numbness	

	

Next available surgeon	

	
Nominated surgeon request 
(if available)	

	

Email acutedisc@nsiwa.com.au
for urgent booking	

Imaging scans conducted at:	

	
SKG	

	
Perth Radiological Clinic	

	
Other	

	

Patient details	
Patient Name:	
<<Patient Demographics:Full Name>>	

Date of Birth:	
<<Patient Demographics:DOB>>	
	
Home Phone:	
<<Patient Demographics:Phone (Home)>>	

Address:	
<<Patient Demographics:Full Address>>	

Email:	
<<Patient Demographics:E-mail>>	

Private Health Fund:	

	
Clinical comments:	

	

	

Current medications:	

	
Patient history:	

	

Acute Disc Service Referral Form	

Referrer details	
Referring doctor name:	
<<Doctor:Name>>	

Practice:	
<<Practice:Name>>	

Provider No:	
<<Doctor:Provider Number>>	

Signature:	

		

	

Copy to:	
<<Addressee:Name>>	

		Date:	
<<Miscellaneous:Date>>	

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