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:

Full name: [PatientFirstName] [PatientSurname] DOB: [PatientDOB]

Fax: 9975 4622

Phone: [PatientMobilePhone] [PatientHomePhone] Gender: [PatientSex]

Email: reception@peninsularespiratory.com.au

Smoking History: [PatientSmokingStatus]

Ph: 9975 4911 to speak to our receptionist

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

Mater Clinic Laboratory

Suite 1.05 Mater Clinic 3-9 Gillies Street
North Sydney NSW 2060

Tests Required Tests for Asthma/Allergy (mark with x)

[  ] Full pulmonary function test (flow volume loop, with bronchodilator, lung volumes, gas transfer capacity)

[  ] Histamine Challenge*

[  ]  Spirometry incl. bronchodilator*

[  ]  Saline Challenge

[  ]  Airway resistance (RAW)

[  ]  Mannitol Challenge*

[  ]  Respiratory muscle strength (MIPS/MEPS)

[  ]  Nasal Resistance*

[  ]  Sniff Nasal Inspiratory Pressure (SNIP)

[  ]  Skin Prick Test*

[  ]  Home oximetry
[  ]  High Altitude Simulation Test (HAST)
[  ]  6 Minute Walk Test (6MWT)
[  ]  Capillary blood gases

Referring Doctor

Name: [ReferringDoctorName] [ReferringDoctorSurname]

Provider #: [ReferringDoctorProviderNo] Date: [ReferralDate]

Doctor's Signature:

Clinic Address: [LocationAddressline1] [LocationAddressline2] [LocationPhone] [LocationSuburb] [LocationState]

A

PENINSULA PULMONARY FUNCTION LABORATORY

Respiratory Physicians Please send this form via:
Fax: 9975 4622
Email: reception@peninsularespiratory.com.au
Ph: 9975 4911 to speak to our receptionist
Frenchs Forest Laboratory: Forest Central Business Park Suite 2, Level 2, Building 1, 49 Frenchs Forest Road East, Frenchs Forest NSW 2086
Mater Clinic Laboratory: Suite 1.05 Mater Clinic 3-9 Gillies Street North Sydney NSW 2060

Dr Keith R Burgess – Medical Director

MB BS, M.Sc, Ph.D, FRACP, FRCPC, FACP

Dr Stanley Braude

MBChB, MD, FRACP, MRCP (UK)

Dr Kate Barclay

MB BS, B Med Sci, MPH & Trop Med, FRACP

Dr Linda Seeto

MB BS (Hons), PhD, FRACP

Dr Patricia Hullah

BAppSc (Phty), MBBS (hons), Dip Pall Med (clinical), FRACP

Dr Philip Lee

BScMed MBBS (Hons) UNSW FRACP

Dr Betty Chen

BSc, MB BS (Hons), MPH, FRACP

Dr Samantha Herath

MBBS (Hons), MPhil, 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.

Mater Clinic Parking: Parking is available, space permitting, at the Mater Hospital and Mater Clinic - hourly rates apply. The entrance is from 25 Rocklands Road. Car Park enquiries Ph (02) 9900 7571.
Bus: Check State Transit for information.
Disabled Access: The Frenchs Forest and Mater Facility have ramp, lift and disabled toilet access