Referral Request

Please complete fields in red and send this form via:

Fax: 9975 4622 Email: reception@peninsularespiratory.com.au Ph: 9975 4911 to speak to reception

Frenchs Forest Laboratory
Forest Central Business Park
Suite 2, Level 2, Building 1,
49 Frenchs Forest Road East,Frenchs Forest NSW 2086

1. Patient details

First name: patient.first_name Last name: patient.last_name

Gender: patient.gender Date of birth: patient.born_on

Phone: patient.home_phone Mobile: patient.mobile_phone

Smoking History (never / ex-smoker / current smoker):

Clinical Notes (please add):

2. Tests Required. Mark with [ X ]

[ ] Full pulmonary function test (flow volume loop, with
bronchodilator, lung volumes, gas transfer capacity)
[ ] Spirometry incl. bronchodilator
[ ] Airway resistance (RAW)
[ ] Respiratory muscle strength (MIPS/MEPS/SNIP)
[ ] Spirometry supine
[ ] Overnight home oximetry
[ ] High Altitude Simulation Test (HAST)
[ ] 6 Minute Walk Test (6MWT)
[ ] Arterial/capillary blood gases
[ ] Shunt study

Tests for Asthma/Allergy

[ ] Histamine Challenge
[ ] Saline Challenge
[ ] Mannitol Challenge
[ ] FeNO (Fractional NO on exhalation)
[ ] Skin Prick Test
[ ] Other (specify):

3. Referring Doctor

Date: current_date

Doctor's Name:

Provider number:

Clinic Address:

Clinic Phone:

4. Doctor's Signature: (or type your name as signature equivalent)

PENINSULA PULMONARY FUNCTION LABORATORY

Respiratory Physicians	Please send this form via:
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 Betty Chen BSc, MB BS (Hons), MPH, FRACP Dr Jian Eu Tai BMed, MD, FRACP Dr Rivindi Watthayalage MBBS, FRACP	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

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.

Bus: Check State Transit for information.