Sleep Test Referral Form — Synergy Sleep

Patient Information

Surname*

Given Name*

Date of Birth (required)*

Sex*

Patient Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medicare No*

Email*

Phone*

Private health insurance

Indications, Symptoms and Health Comorbidities*

For a Medicare subsidised sleep study a patient must score 8 or more on the following questions below.

How likely are you to fall asleep if you are sitting & reading?*

How likely are you to fall asleep if you are watching television?*

How likely are you to fall asleep if you are sitting inactive in a public place (i.e theatre or meeting)*

How likely are you to fall asleep lying down in the afternoon, when circumstances permit?*

How likely are you to fall asleep if sitting and talking to someone?*

How likely are you to fall asleep sitting quietly after lunch without alcohol?*

How likely are you to fall asleep as a passenger in a car for an hour without a break?*

How likely are you to fall asleep in a car as a driver stopped for a few minutes in traffic?*

Other clinically relevant notes.

Please Specify

Telehealth Consultation

Date*

Dr's Provider No*

Declaration*

I declare that I am the referring doctor for the above named patient, I have completed this referral form and furthermore, I authorise the referral to be actioned on my behalf.
I declare that I have discussed the referral with my doctor and have been provided authorisation from my doctor to complete the referral form & provide all relevant details pertaining to the doctors details

Dr's Name*

Medical Center or Dr's Clinical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical Center or Dr's clinical Phone number*

Medical Center or Dr's clinical Fax*

Medical Center or Dr's clinical Email*

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