Dental Referral - www.respirologist.com.au

DIRECT REFERRAL FOR DIAGNOSTIC SLEEP STUDY

The electronic referral on this page is only for use by dentists.

We will contact the patient to arrange the study. Need to talk to us? We'd be happy to talk to you - please ring the rooms on 07 3123 5350 or email reception@respirologist.com.au.

The cost to the patient for a diagnostic sleep study is $430. This is a home based study. Please be aware that scoring a sleep study is a time consuming process - we aim to provide the report to you within 5 business days following the night of the study.

Referral Date*

Patient Name*

First Last

Patient DOB*

Patient Gender*

Patient Mobile Tel*

Patient Home Tel

Clinical notes*

Please outline indication for sleep study and any other relevant information and background.

Referrer Name*

Referrer Provider Number*

Referrer Practice Name and Suburb*

Referrer Telephone Number*

Referrer Signature*

Result Delivery Preference*

Address for delivery of results

Email address for delivery of results

Fax number for delivery of results