<<Peninsula Respiratory eReferral>> eninsula Sleep Clinic eReferral
	PENINSULA PULMONARY
FUNCTION LABORATORY
  Ph: 9975 4911 Fax: 9975 4622 reception@peninsularespiratory.com.au www.peninsularespiratory.com
		
Referral Request
<Patient Details> procedure
Patient details	Please send this form via:	
Full name: <<Patient Demographics:Full Name>> Date of birth: <<Patient Demographics:DOB>>	Fax: 9975 4622	
Phone:<<Patient Demographics:Phone (Home)>> <<Patient Demographics:Phone (Mobile)>>  Gender: <<Patient Demographics:Gender>>	Email: reception@peninsularespiratory.com.au	
Smoking History: <<Smoking History>>	Ph: 9975 4911 to speak to our receptionist	
Clinical Notes: <<Clinical Notes (please add any notes here)>>	HealthLink ID: peninres

Frenchs Forest Laboratory 
Forest Central Business Park 
Building 1, Level 2, Suite 2, 
49 Frenchs Forest Road East, 
Frenchs Forest NSW 2086

Patients can now book online via HotDoc on www.peninsularespiratory.com.au 
<<Tests Required (Tick to select)>>	
Tests Required                                                                    Tests for Asthma/Allergy	
<<Full pulm func (flow/lung vol, brnchdilatr, gas trans)>> Full pulmonary function test (flow volume loop, with bronchodilator, lung volumes, gas transfer capacity)	

<<Spirometry incl. bronchodilator>> Spirometry incl. bronchodilator	

<<Airway resistance (RAW)>> Airway resistance (RAW)	

<<Respiratory muscle strength (MIP/MEP/SNIP)>> Respiratory muscle strength (MIPS/MEPS) 	

<<Overnight home oximetry>> Overnight home oximetry	

<<High Altitude Simulation Test (HAST)>> High Altitude Simulation Test (HAST)	

<<6 Minute Walk Test (6MWT)>> 6 Minute Walk Test (6MWT)	

<<Arterial/capillary blood gases>> Arterial/capillary blood gases	

<<Shunt Study>> Shunt study	

<<Spirometry supine>> Spirometry supine	

	<<Histamine Challenge >> Histamine Challenge 	

<<Saline Challenge >> Saline Challenge 	

<<Mannitol Challenge >> Mannitol Challenge  	

<<Skin Prick Test>> Skin Prick Test	

<<Fractional NO on exhalation (FeNO)>> Fractional NO on exhalation (FeNO)	

Other: <<Other>> 	

	

Referring Doctor		
Name: <<Doctor:Name>>	Provider #: <<Doctor:Provider Number>>    Date: <<Miscellaneous:Date (short)>>	
Doctor's Signature: <<*Doc Signature* (type name as sig equivalent)>>	Clinic Address: <<Practice:Address>>	

A
PENINSULA PULMONARY FUNCTION LABORATORY

Respiratory Physicians

Dr Keith R Burgess – Medical Director
MB BS, M.Sc, Ph.D, FRACP, FRCPC, FACP
Dr Stanley Braude
MBChB, MD, FRACP, MRCP (UK)
Dr Linda Seeto
MB BS (Hons), PhD, FRACP
Dr Betty Chen
BSc, MB BS (Hons), MPH, FRACP
Dr Jian Tai
BMed, MD,FRACP
Dr Rivindi Watthayalage
MBBS, FRACP	Please send this form via:

Fax: 9975 4622
Email: reception@peninsularespiratory.com.au
Ph: 9975 4911 to speak to our receptionist
Book online via HotDoc
HealthLink ID: peninres
Peninsula Pulmonary Function Laboratory 
Forest Central Business Park 
Building 1, Level 2, Suite 2, 
49 Frenchs Forest Road East, 
Frenchs Forest NSW 2086

Our Location:
Peninsula Pulmonary Function Laboratory 
Forest Central Business Park 
Building 1, Level 2, Suite 2, 
49 Frenchs Forest Road East, 
Frenchs Forest NSW 2086

 
Free Parking: Patient parking is available underneath the building from 0730. Building 1 is on the left as you enter the Business Park. Proceed just past Building 1 and turn left into the first driveway. At the boom gate press Peninsula Respiratory Group on the keypad and wait for it to be answered. Park only in the spaces marked Peninsula Respiratory / Sleep Laboratory. Alternatively, there is parking in the surrounding streets.

Public transport: Bus route 166 stops in front of our clinic. Please check www.transportnsw.info for the latest information