For an appointment please complete all details and Fax to 03 93184577. We will contact your patient within 24 hours.
PATIENT DETAILS
<PtDetails>DOB <PtDoB> 	Sex <PtSex> 	Telephone <PtPhoneH> Mobile <PtPhoneMob>
Medicare number: <PtMCNo><PtMCLine> Expiry <PtMCExpiry>

REFERRING DOCTOR DETAILS
<DrDetails>
Provider number <DrProviderNo>	Telephone <DrPhone>

DOCTOR SIGNATURE:___________________________________ 	DATE: <TodaysDate>

CLINICAL NOTES: <TodaysVisit>

ALLERGY
Information needed:
Are RAST or other relevant test results available? <RAST results available>
Note: For patch testing assessment of contact hypersensitivity by nickel allergy, please refer the patient to a dermatologist

MAJOR PROBLEMS
Angiodoema<Angioedema>	Allergy rhinitis<Allergy rhinitis>	Asthma<Asthma>	Drug allergy<Drug allergy>	Eczema<Eczema>	Food allergy<Food allergy>	Stinging insect allergy<Stinging insect allergy>	Urticaria<Urticaria>
Other <Other allergy problem>

SLEEP STUDY
SERVICES REQUIRED: <Sleep studies required>

CLINICAL DETAILS
Snoring<Snoring>	Witnessed apnoea<Witnessed apnoea>	Insomnia<Insomnia>	Interrupted sleep<Interrupted sleep>	Morning headache<Morning headache>	Loss of libido<Loss of libido>	Memory loss<Memory loss>	Restless legs<Restless legs>	Occupational requirement<Occupational requirement>	Excessive daytime somnolence<Excessive daytime somnolence>

Note: This request includes referral to a qualified sleep physician who will confirm the necessity for a sleep study, where requested, as per Medicare requirements.

LUNG FUNCTION
RESPIRATORY TESTS REQUIRED:<Respiratory tests required>

IMPORTANT PRIOR TO RESPIRATORY TESTS:
No short term bronchodilators to be used for 4 hours, unless required (eg Ventolin, Atrovent, Asmol etc)
No long term bronchodilators to be used for 12 hours, unless required (eg Serevent, Oxis, Seretide, Symbicort etc)

OUR LOCATIONS	PHYSICIAN CONSULT	SLEEP STUDY	LUNG FUNCTION	ALLERGY CONSULT	

WESTERN						
Bacchus Marsh 3340	Bacchus Marsh Eye Clinic, 16 Grant St	Y	Y			
Brunswick 3056	Brunswick Private Hospital Consulting Suites, 82 Moreland Rd	Y	Y			
Flemington 3031	Flemington Consulting Rooms, Suite 31, 320-380 Epsom Rd	Y		Y		
Footscray 3011	Footscray Consulting Rooms, 35 Summerhill Rd	Y	Y	Y	Y	
Gisborne 3437	Gisborne Medical Centre, 16 Brantome St	Y	Y			
Sydenham 3037	Sydenham Specialist Suites, 574 Melton Highway	Y	Y	Y		
Sunbury 3429	Sunbury Suites, 17-19 Horne Street	Y		Y		
Werribee 3030	Wyndham Private Specialist Consulting Rooms, Level 1, 
242 Hoppers Lane	Y	Y	Y		
Williamstown 3016	Williamstown Consulting Rooms, 110 Douglas Parade	Y				

NORTHERN						
Epping 3076	Epping Specialist Centre, Level 2, 230 Cooper St	Y	Y			
Niddrie 3042	North West Specialist centre, Suite 6, Level 1, 326 Keilor Road	Y	Y	Y	Y	

EASTERN						
Box Hill 3128	Box Hill Consulting Rooms, Suite 1, 28-32 Arnold St	Y	Y	Y		

SOUTH EASTERN						
Berwick 3806	St John of God (Stephenson House), Suite 2, 8 Gibb Street		Y			
Frankston 3199	Peninsula Private Hospital, Suite 7, 525 McClelland Dve 	Y	Y			
Malvern East 3145	Central Park specialist Centre, 389 Wattletree Road	Y	Y	Y		
Patterson Lakes 3197	Bayside Specialist Centre, Suite 29, Level 1, 21 Thompson Road	Y	Y	Y		
Springvale 3171	Springvale Suites, 8 Windsor Avenue	Y	Y			
Malvern 3145

	Cabrini Medical Centre Suite 32, 183 Wattletree Road	Y	Y	Y		

RURAL / TELEHEALTH						
Ballarat 3350	Ballarat Consulting Rooms, 710 Sturt Street	Y	Y			
Foster 3960	Foster Medical Centre, 97 Station Road	Y	Y	Y	Y	
Rosebud 3939	Rosebud Specialist Centre, 1385 Point Nepean Road		Y			
Sebastapol 3356	Sebastopol Consulting Rooms, 49-51 Albert Street	Y	Y			
Seymour 3660	Seymour Medical Clinic (Telehealth), 30-32 Anzac Avenue	Y	Y