Concussion baseline
Screening Questionnaire

I am consenting for myself or my child (if appropriate) to have a Baseline Concussion Screening Assessment administered. I understand that:

• Testing may include a survey about mental wellbeing and sleep, relevant medical history including previous concussions, vestibular-occular assessment with Neuroflex VR technology, balance tests and cognitive testing.
• Engage VR may provide information to your GP, Neurologist, other treating Physician, Allied healthcare professional or the organisation that you have stated above in the personal details section. We will first contact you and obtain specific consent (verbal or written) to release this information to the nominated parties.
• If you have been referred by a specific organisation and they have paid for the Screening Assessment, by nominating that organisation above, we assume consent to release relevant information to that organisation.
• Data from these tests may be used for research into brain health and concussion. All research data will remain secure and de-identified.
• All data is kept secure according to the Australian Privacy Act 1988.

1. Cancellations require at least 2 business days' notice. If less notice is given, the full fee for the service will be charged, as we are unable to rebook clinicians at short notice.
2. Please notify reception if you are running late.
3. To respect everyone's time, we kindly ask that you arrive on time for your appointment. If you arrive late, your session may need to be shortened to ensure the next appointment can start as scheduled. Thank you for your understanding.