Some people who have sleep apnoea may have other health issues.

Do you suffer from any of the following? (select all that apply, leave blank if none apply)

To complete your referral letter, we need to ask a little more about your medical history

Please select any conditions from the following that apply to you now, or applied to you in the past (leave blank if none apply)

Please specify cancer*

Please specify illness*

Have you had any surgery in the past?*

Yes
No

Please select any of the following that apply to you: (can select more than one)

Have you had an allergy or bad reaction to any of the following medications? (Leave blank if none apply)

I agree to provide an up-to-date list of all my medications to my specialist when I attend for my appointment*

Yes
No

Please enter your Medicare details, so you can access rebates, where appropriate.

Enter medicare details

If you become unwell while awaiting a sleep study (including chest pain, chest tightness, shortness of breath, weakness or dizziness) it is very important you seek urgent medical attention*

Do you understand this advice?

Yes
No

Please select the specialist/provider you wish to attend for your sleep study*

Would you like us to email your referral letter directly to the above specialist? (This is the most efficient way to get your referral letter to your provider).

Yes, please send to the specialist directly
No thanks, just email to me, and I will send it to them myself

If you can’t find your sleep study provider in the above menu, type the details below (in this case we will just email the completed referral form to you, and you can give it to the specialist/provider):

Specialist/Provider Name*

Specialist/Provider Address*

Please add the details of your local/usual GP:

GP's Name*

GP's Address*

Please select the store or pharmacy who suggested you complete this online assessment with Qoctor*

Special Notes

Referral Reason

Referral pathway for Sleep Studies

Step 1 of 4

Reviews

Sleep Physician referral

Vasectomy – New Referral Letter

Medication/Prescription

Acne New Referral Letter