I am a person with a confirmed diagnosis of MND or Kennedy’s disease
I am a person with a NDIS plan who has a diagnosis other than MND or Kennedy’s disease
I am a family carer who is supporting a family member or friend who has MND
Home Address
Mailing Address (if different to the above)
Details
Your health, disability or medical condition
If you are not sure of the dates, please make a best estimate. We can always update these dates from information you provide to us in the future.
Alternate Contact
By providing us with an alternate contact, you and the alternate contact consent for MND NSW to create a record and consent for MND NSW to communicate with them about your care needs, if required. Please note that an MND NSW staff member will seek direct confirmation from the person seeking Program entry unless it is not practical to do so.
About the Person MND NSW may communciate with
Consent to record (required)
In completing this form, you are giving your consent for MND NSW to record your personal information and create a health record. MND NSW will provide a separate service agreement for each program you are eligible for. You can choose to accept or decline service agreement/s provided to you by MND NSW.
Completing this form on behalf of someone else?
If you are completing this form on behalf of someone else, please provide your details: