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


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)
[   ]  Sniff Nasal Inspiratory Pressure (SNIP)
[   ]  Home oximetry*
[   ]  High Altitude Simulation Test (HAST)
[   ]  6 Minute Walk Test (6MWT)
[   ]  Capillary blood gases
Tests for Asthma/Allergy

[   ]  Histamine Challenge*
[   ]  Saline Challenge
[   ]  Mannitol Challenge*
[   ]  Nasal Resistance*
[   ]  Skin Prick Test*


*Also at Mater Clinic

 

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 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  
Fax: 9975 4622
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


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