Online Referral

Patient Details

Conditions/Symptoms (Please Tick Appropriate Boxes Below)

Appointment Details

Referral Type

Cardiac Services

Preferred Cardiologist (General Consulting)
Preferred Cardiologist (Interventional)
Preferred Cardiologist (Arrythmia Clinic - EP)
Preferred Cardiologist (CT Coronary Angiogram)
(Subject to a 2 year referral restriction, cannot be claimed if echo was claimed within 24 months)
For echocardiogram please select indications:
(Subject to a 2 year referral restriction, can only be bulk billed once every 2 years)
For stress echo please select indications below:
Can only be Bulk Billed once per every 4 weeks

Sleep & Respiratory Services

(Combined Spirometry & Gas Transfer Factor)
Preferred Respiratory & Sleep Disorders Physician
Home based Sleep study (MBS 12250) For suspected sleep apnea. If deemed necessary, a Sleep Physician appointment may be arranged, who will arrange appropriate treatment if required. Once selected, please fill out the questionnaire below.
Preferred Location/s *
Disclaimer : Not all procedures may be available at the selected location(s).

For Sleep Investigation, you must please complete the questionnaire below:

The Epworth Sleepiness Scale Test

How likely are you to doze off or fall asleep in the situations described, in contrast to feeling just tired?

This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how they have affected you. Use the scale test on the left to choose the most appropriate number for each situation.

0 - Would never doze
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing

0
0
0
0
0
0
0
0

Score Result:

0 - 7 = Normal  (Bulk billing not applicable)

8 - 24 = Abnormal  (Complete questionnaire below)

There is no need to enter a number.

Results have shown to be abnormal. Please complete only one of the questionnaires below to determine if
the patient is eligible for bulk-billing.

 

Fill in either one of the following:

 

Stop - Bang Sleep Apnea Questionnaire for Patient :
Minimum 3 Ticks to Qualify *

Do you SNORE loudly (loud enough to be heard through closed doors?)
Do you often feel TIRED, fatigued or sleepy during anytime?
Has anyone OBSERVED you stop breathing or choking during your sleep?
Do you have or are you being treated for high blood PRESSURE?
BMI more than 35kg/m2?
AGE older than 50 years?
NECK size large (Males: 43cm+ & Females: 41cm+)?
GENDER = male?
Must be greater than 3 to be eligible for bulk billing. If patient has not met the criteria, consider the OSA 50 Screening questionnaire.

The results meet requirements for bulk billing.

OSA 50 Screening Questionnaire
To Qualify for Bulk-Billing a patient must score 5 or more

Confirm Sex
Waist measurement at the umbilicus level in (cm). To be eligible: Weight circumference must be: Males > 102cm; Females > 88cm
Snoring: Has your snoring ever bothered other people? =3
Apneas: Has anyone noticed that you stop breathing during sleep? =2
Age 50+: Are you aged 50 years or over? =2
Must be greater than 5 to be eligible for bulk billing. If patient has not met the criteria, consider the Bang Sleep Apnea Questionnaire.

The results meet requirements for bulk billing.

Referring Doctor Details

Automatically inputted. There is no need to add a date here.
Please draw your signature with a mouse (pen) or type your name (keyboard) to sign.


Acknowledgment

By signing and pressing the submit button, you acknowledge that you are a medical practitioner wanting to make a referral and have checked to ensure all the correct information has been entered. If you are NOT a medical practitioner, please note that the named patient will not be able to claim Medicare benefits without a valid referral.