Vestibular Patient Registration

To register, please take the time to fill out the information below.

Dizziness ScaleNo DizzinessSometimes DizzyOften DizzyVery Often DizzyMost of Day Spent DizzyDizziness Scale
Do you have any other Medical Conditions

I agree to give 24 hours notice if I cannot attend my appointment (to be given to someone in need of urgent treatment). If I do not give notice I agree to pay a fee of €30. If I do not attend my appointment and I have not called, I agree to pay the full consulting fee.

Your Signature