Referral Form

NOTE FOR REFERRING DOCTORS: Patients under 18 years of age should be referred to a paediatric sleep physician.	

Reporting physicians
Dr. Michael Hayes FRACP
Dr. Chris Duggan FRACP
A/Prof. Stephen Cala FRACP
Dr. Alex Erdstein FRACP
	
 Pacific Sleep
Gosford	
Central West	

Toukley	
Newcastle 	

Blacktown	
Hornsby	

	

Tel   02 4339 1222	

Fax  02 4339 1617	

Please fax your referral to 02 4339 1617 or email referrals@pacificsleep.com.au.
Patients: Please bring this referral to your appointment.

Patient name: <PtFullName>	Date of Birth:<PtDoB>	
Address: <PtAddress>	
Telephone: <PtPhoneMob>	Email: <PtEmail>	
Commercial drivers licence: <Commercial drivers licence>	
<SYMPTOMS AND MEDICAL CONDITIONS>
SYMPTOMS AND MEDICAL CONDITIONS 	
<Hypertension> Hypertension	<Snoring> Snoring	<Artial fibrillation> Artial fibrillation	
<Cardiac failure> Cardiac failure	<Overweight> Overweight	<Daytime somnolence> Daytime somnolence	
<Stroke / TIA> Stroke / TIA	<Pacemaker> Pacemaker	<Family history (OSA)> Family history (OSA)	
<COPD> COPD	<Type II Diabetes> Type II Diabetes	<Clinical history>Clinical history
(optional, attach notes to this referral)	
<Symptoms and Medical Conditions Other> Other: <Symptoms and Medical Conditions - Other>	
<REQUEST FOR (please tick the appropriate box/boxes)>
REQUEST FOR (please tick the appropriate box/boxes)	
<Home diagnostic sleep study (includes consultation with the reporting physician)> Home diagnostic sleep study (includes consultation with the reporting physician)	
<Implement CPAP treatment (with oximetry as required)> Implement CPAP treatment (with oximetry as required)	<Multiple Wakefulness Test (MWT)> Multiple Wakefulness Test (MWT)	
<Pressure review study (with oximetry)> Pressure review study (with oximetry)	<Attended sleep study> Attended sleep study	
<Supply of oxygen concentrator> Supply of oxygen concentrator	<Supply of DVA approved equipment & services> Supply of DVA approved equipment & services	
Other: <Request for - Other>	

REFERRING DOCTOR	
Referring Dr. name <DrName>	
Practice name <LocationName>	Provider no. <DrProviderNo>	
Address <DrAddress>	
Email <DrEmail>	
Phone <DrPhone>	Fax <DrFax>	
Referring Dr. signature	Referral date <Referral Date>	

Pacific Sleep locations
Blacktown
Blacktown Town Centre
Suite 9, 30 Campbell Street
Blacktown NSW 2148	Cowra
110 Kendal Street
Cowra NSW 2794	Gosford
Jarrett Street Specialist Centre
Suite 2, 14-18 Jarrett Street
North Gosford NSW 2250	
Gympie, Qld
Mobile service	Hornsby
Suite 6B, Level 2
26 Florence Street
Hornsby NSW 2077	Newcastle
663 Glebe Road
Adamstown NSW 2289	
Parkes
Parkes General Practice
25 Church Street
Parkes NSW 2870	Toukley
Suite 2, 45 Canton Beach Road
Toukley NSW 2263		

Approved DVA Supplier providing
CPAP equipment for eligible DVA clients.	
Registered NDIS Provider

Referrals
Please send your referral to us by fax on
02 4339 1617
or email to
referrals@pacificsleep.com.au

Information
For more information, please call our office on
02 4339 1222
or send us an email at
info@pacificsleep.com.au
or visit our website
www.pacificsleep.com.au