Online Referral for GPs

Lung function tests and eligible home-based sleep studies are bulk billed with a valid referral. Consultation fees and any hospital-based sleep study charges are separate; reception will explain the applicable fees before booking.

This form is for referring clinicians. Patients who already have a referral letter should use Upload your referral.

Referral priority
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Please enter the date of birth as dd/mm/yyyy.
Please enter the date of birth as dd/mm/yyyy.
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Sleep Study
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* Please complete the ESS and STOP-Bang questionnaires. For a direct referral based on screening scores, Medicare requires ESS ≥ 8 and either STOP-Bang ≥ 3, OSA-50 ≥ 5 or a high-risk Berlin score.
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Respiratory Function Tests
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Preferred clinic
  • No preference – closest to the patient
  • No preference – closest to the patient
  • Epping
  • Brunswick
  • Doncaster East
  • Braybrook
  • Kilmore
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Withholding times for lung function tests

If you are ordering lung function tests, please give the patient these withholding times — a long-acting inhaler taken that morning may invalidate the pre-bronchodilator result, and the test may have to be repeated. Patients should not stop a medicine they need to stay safe. Printable patient version →

Medicine (examples)Spirometry, lung volumes, gas transfer, FeNOBronchial provocation (mannitol)
Reliever puffers — salbutamol (Ventolin, Asmol, Airomir), terbutaline (Bricanyl)4–6 hours8 hours
Ipratropium (Atrovent)12 hours12 hours
Twice-daily long-acting and combination inhalers — Seretide, Symbicort, Flutiform, DuoResp, Fostair, Serevent, Oxis24 hours36 hours
Once-daily long-acting inhalers — Breo Ellipta, Trelegy, Anoro, Ultibro, Spiolto, Onbrez, Striverdi36–48 hours72 hours
Twice-daily triple-therapy inhalers (they contain a long-acting anticholinergic) — Trimbow, Breztri36–48 hours72 hours
Long-acting anticholinergics — Spiriva, Seebri, Incruse, Bretaris36–48 hours72 hours
Preventer-only inhaled steroid — Flixotide, Pulmicort, Qvar, AlvescoTake as usualSkip the morning dose (6 hours)
Montelukast (Singulair)Take as usual4 days
Antihistamines — Zyrtec, Claratyne, Telfast, PhenerganTake as usual72 hours
Theophylline (Nuelin)Take as usual24 hours
Caffeine — coffee, tea, cola, energy drinks, chocolateAvoid on the morning of the test24 hours
Smoking or vapingNot within 1 hourNot within 1 hour
AlcoholNot within 8 hoursNot within 8 hours
Vigorous exercise · a large mealNot within 1 hour · not within 2 hoursNot within 1 hour · not within 2 hours
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Attach the referral letter (optional)
A PDF, or a photo of each page (JPG, PNG or HEIC). Up to 3 files, 10 MB each. If you attach nothing, this form itself is filed as the referral.
Choose file(s)
Please attach a PDF, JPG, PNG or HEIC file of 10 MB or less.
Please attach a PDF, JPG, PNG or HEIC file of 10 MB or less.

Requesting Doctor

Please enter your first name.
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Please enter your surname.
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Please enter the practice email address.
Please enter the practice email address.

Signature: please enable JavaScript to sign on screen.

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EPWORTH SLEEPINESS SCALE (ESS)

Use the 0–3 scale to choose the most appropriate number for each situation
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0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
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SITUATION

CHANCE OF DOZING (0 – 3)

Sitting and reading
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+
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Watching TV
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Sitting, inactive in a public place (e.g. a theatre or a meeting)
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+
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As a passenger in a car for an hour without a break
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+
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Lying down to rest in the afternoon when circumstances permit
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+
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Sitting and talking to someone
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Sitting quietly after a lunch without alcohol
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In a car, while stopped for a few minutes in the traffic
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+
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Write down total score
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For a direct referral based on screening scores, the ESS score needs to be ≥ 8.
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STOP-Bang QUESTIONNAIRE

Do you SNORE loudly?
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Do you often feel TIRED, fatigued, or sleepy during the daytime?
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Has anyone OBSERVED you stop breathing or choke or gasp for air during your sleep?
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Do you have or are you being treated for high blood PRESSURE?
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BMI more than 35 kg/m²?
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Age over 50 years old?
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Neck circumference 43 cm or more (men) / 41 cm or more (women)?
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Gender: Male?
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Write down total YES score
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For the STOP-Bang direct-referral pathway, the STOP-Bang score needs to be ≥ 3 and the ESS score needs to be ≥ 8.
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Submit

Online Referral