Referral Form

Please complete the details below. Alternatively, you can download a PDF referral form here, fill it out offline, and then email it back to us.

 

    Patient Details

    Services requested (Please choose one or more)

    Please kindly assist us by providing the following information
    In accordance with the MBS, a Consultant Sleep Physician will assess the following information to determine whether the sleep study is eligible for a Medicare-rebate.

    A. STOP BANG Questionnaire
    Does your patient have any of the following? Please tick when applicable

    B. Epworth Sleepiness Scale
    How likely is your patient to doze off or fall asleep in the following situations, in contrast to feeling just tired? Please score each

    0 = would never doze   1 = slight chance of dozing   2 = moderate chance of dozing   3 = high chance of dozing

    C. Does your patient have any of the following conditions? If "YES", Please please tick the box below

    For this referral to be valid, please ensure the following details are completed:

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