Patient Name: <PtFullName>	Phone: <PtPhoneMob>	
Email: <PtEmail>	Commercial Drivers Licence:  <Commercial Drivers Licence>	

Symptoms (please tick appropriate boxe/s)	
<Snoring> Snoring	<Daytime lethargy/sleepiness> Daytime lethargy/sleepiness	
<Witnessed apneas/nocturnal gasping/chocking> Witnessed apneas/nocturnal gasping/chocking		
Relevant Medical Conditions (please tick appropriate boxe/s)	
<Hypertension>  Hypertension	<Cardiac Failure> Cardiac Failure	<Stroke/TIA> Stroke/TIA	
<Type II Diabetes>Type II Diabetes	<Atrial Fibrillation>Atrial Fibrillation	<Obesity>Obesity	
Other: <Other>	Clinical History: <Clinical History>		
Request for (please tick appropriate boxe/s)	

<Home sleep test for suspected Sleep Apnea> Home sleep test for suspected Sleep Apnea (In accordance with Medicare item 12250, all sleep assessments and appropriateness of home tests are overseen by the supervising Sleep Physician.  Based on these assessments and the study findings, certain complex patients may require a Sleep Physician consultation)	
<CPAP/APAP Treatment Trial> CPAP/APAP Treatment Trial - for the treatment of Sleep Apnea	
<Mandibular Advancement Oral Devices - snoring only> Mandibular Advancement Oral Devices - snoring only (fitted by a Dentist)	
<Mandibular Advancement Oral Devices - snoring and mild apnea> Mandibular Advancement Oral Devices - snoring and mild apnea - for the treatment of Snoring and mild to moderate Sleep apnea (fitted by a Dentist) 	
<VPAP Adapt Treatment Trial - for the treatment of suspected> VPAP Adapt Treatment Trial - for the treatment of suspected Complex Sleep Apnea and/or Central Sleep Apnea (ASV therapy is contraindicated in patients with chronic, symptomatic heart failure with reduced left ventricular ejection fraction LVEF<45%)	
<VPAP S/ST/ST-A Treatment Trial - for the treatment of suspec> VPAP S/ST/ST-A Treatment Trial - for the treatment of suspected COPD or for pressure assited therapy	
<Pressure/Treatment Review with Oximetry> Pressure/Treatment Review with Oximetry

FOR THIS REFERRAL TO BE VALID, PLEASE ENSURE THAT THE FOLLOWING DETAILS ARE COMPLETED:

Referring Doctor:<DrFirstName> <DrSurname>	
Doctor's Signature:	
Provider Number:<DrProviderNo>	Date of Referral: <TodaysDate>	
Practice Name: <Practice>	Phone: <UsrPhone>	
Address: <UsrAddress>		
Email: <PracEmail>	Fax: <UsrFax>	

Please indicate how you would like to receive results and other correspondence from ResSleep:
	
<Electronic transfer of reports via secure messaging>Electronic transfer of reports via secure messaging	<Email>Email	<Fax>Fax	<Post>Post	

Clinic Locations

New South Wales
Bella Vista
1 Elizabeth Macarthur Drive
Bella Vista  NSW  2153	Newcastle
356 Hunter Street
Newcastle  NSW  2300	South Australia
Brighton
425 Brighton Road
Brighton  SA  5048	

Bondi Junction
Suite 1104, Level 11
1 Newland Street	
Bondi Junction  NSW  202		North Ryde
Suite 8, 33 Waterloo Road
North Ryde  NSW  2113
	
North Adelaide
120 Childers Street
North Adelaide  SA  5006	

Dee Why
850 Pittwater Road
Dee Why  NSW  2099
	Sydney CBD
Mezzanine Level, Kyle House
27-37 Macquarie Place
Sydney  NSW  2000	St Agnes
6/1240 North East Road
St Agnes  SA  5097	
Gosford
Suite B, 201 Mann Street
Gosford  NSW  2250		
Queensland
Chermside
960 Gympie Road
Chermside  QLD  4032	Victoria
Kew
154 High Street
Kew  VIC  3101	
Hawkesbury
41 March St 
Richmond  NSW  2753
	
Greenslopes
496 Logan Road
Greenslopes  QLD  4120	
Mt Waverley
Suite 1, 304 Stephensons Road
Mt Waverley  VIC  3149	
Hornsby
Suite 2, Rear Ground Floor	
149 Pacific Highway
Hornsby  NSW  2077	
Mt Gravatt
1389 Logan Road
Mt Gravatt  QLD  4122	
Western Australia
Joondalup
Suite 13, Shenton House
57 Shenton Avenue
Joondalup  WA  6027	
Miranda
Suite 201, 29 Kiora Road	
Miranda  NSW  2228

	North Lakes
9 Gregor Street West
North Lakes  QLD  4509	
Perth CBD
Suite 27, Mount Medical Centre
146 Mounts Bay Road
Perth  WA  6000