PENINSULA PULMONARY FUNCTION LABORATORY
Ph: 9975 4911 Fax: 9975 4622
reception@peninsularespiratory.com.au
www.peninsularespiratory.com
Referral Request
Patient details |
Please send this form via: |
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Full name: [PatientFirstName] [PatientSurname] DOB: [PatientDOB] |
Fax: 9975 4622 |
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Phone: [PatientMobilePhone] [PatientHomePhone] Gender: [PatientSex] |
Email: reception@peninsularespiratory.com.au |
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Smoking History: [PatientSmokingStatus] |
Ph: 9975 4911 to speak to our receptionist |
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Clinical Notes: PLEASE ENTER NOTES HERE |
Frenchs Forest Laboratory Forest Central Business Park Suite 2, Level 2, Building 1, 49 Frenchs Forest Road East, Frenchs Forest NSW 2086
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Tests Required Tests for Asthma/Allergy (mark with x) |
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[ ] Full pulmonary function test (flow volume loop, with bronchodilator, lung volumes, gas transfer capacity) |
[ ] Histamine Challenge* |
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| [ ] Spirometry incl. bronchodilator* | [ ] Saline Challenge |
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| [ ] Airway resistance (RAW) | [ ] Mannitol Challenge* |
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| [ ] Respiratory muscle strength (MIP/MEP/SNIP) | [ ] FeNO* (Fractional NO on exhalation) |
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| [ ] Spirometry supine | [ ] Skin Prick Test* |
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| [ ] Overnight home oximetry | [ ] Other (specify): |
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| [ ] High Altitude Simulation Test (HAST) | ||||
| [ ] 6 Minute Walk Test (6MWT) | ||||
| [ ] Arterial/capillary blood gases | ||||
| [ ] Shunt study | ||||
Referring Doctor |
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Name: [ReferringDoctorName] [ReferringDoctorSurname] |
Provider #: [ReferringDoctorProviderNo] Date: [ReferralDate] |
Doctor's Signature: |
Clinic Address: [LocationAddressline1] [LocationAddressline2] [LocationPhone] [LocationSuburb] [LocationState] |
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PENINSULA PULMONARY FUNCTION LABORATORY
Respiratory Physicians Please send this form via:
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Dr Keith R Burgess – Medical Director MB BS, M.Sc, Ph.D, FRACP, FRCPC, FACP |
Dr Stanley Braude MBChB, MD, FRACP, MRCP (UK) |
Dr Linda Seeto MB BS (Hons), PhD, FRACP |
Dr Patricia Hullah BAppSc (Phty), MBBS (hons), Dip Pall Med (clinical), FRACP |
Dr Betty Chen BSc, MB BS (Hons), MPH, FRACP |
Dr Jian Eu Tai BMed, MD, FRACP |
Dr Rivindi Watthayalage MBBS, FRACP |
Frenchs Forest Parking: Patient parking is available underneath the building from 0730. Building 1 is on the left as you enter the Business Park. Proceed just past Building 1 and turn left into the first driveway. At the boom gate press Peninsula Respiratory Group on the keypad and wait for it to be answered. Park only in the spaces marked Peninsula Respiratory / Sleep Laboratory. Alternatively, there is parking in the surrounding streets.