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*

Have you had any surgery in the past?*

Yes
No

Please select any of the following that apply to you:

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

Do you have a valid Medicare card?

Yes
No

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

Enter medicare details

Please enter your Medicare details, so you can access Medicare 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 assessment*

Would you like us to email your referral letter directly to the above specialist today?(we'll also email you a link for your own records)

Yes, send to my specialist and to me
No thanks, just email it to me

Enter sleep testing/sleep specialist provider details below(Qoctor will send a completed referral form to your Qoctor account- you need to download it and give it to the provider yourself)

Specialist/Provider Name*

Specialist/Provider Address*

Please add the details of your local/usual GP, (if you have one):

GP's Name

GP's Address

If a CPAP Store or Pharmacy directed you to use this online assessment with Qoctor, please indicate the store/pharmacy location below (not mandatory).

Special Notes

Service Request

Physician Consultation
Home Sleep Study
CPAP Clinic
Lung Function Testing

Specialty

Respiratory
Sleep
Cardiology

Consult Type

Face-to-Face
Telehealth

Funding

Medicare
Self-Funded

Other

Assessment pathway for sleep apnoea referral

Reviews

Referral To Sleep Physician – THE SLEEPHEALTH CLINIC

Female Sterilization – New Referral Letter

Sleep Physician referral

Obstructive Sleep Apnoea Referral Letter