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ResMed

REFERRAL FORM
Please send you r ref err al to us by Fax: 1800 317 339 or via secure messaging
Our stat will contact the patient to book an appointment Patients Please bring this ·eferral to your appointment .

Full name	 			 	                                                                                                                Email			Phone I Mob

DOB
Co mmercial drivers licence O Yes O No

Req u est for a Referral (Please mark appropriate options)
0 Home sleep study - This referral covers both o Home Sleep Study, and it required, sleep physician consultation
0 CPAP/APAP trial for the treatment of sleep apnea
0 Mandibular advancement oral device for the treatment of snoring and sleep apnea
0    CPAP therapy review  (pressure, compliance,  mask review &  full equipment check)
0 Supply of OVA approved equipment and services

Both 0SA 50 AND ESS scores must be completed to qualify for a Medicare rebatted Home Sleep Study (Medicare item 12250)

	
ESS Qu estionna ir e - Patient must score 8 or more.
How likely are you to doze off (fall asleep) in the followin g sit uat ions?		
	Sitting and reading	O D		0 1	0	2	0 3	
	"'    Watching television	O D		0 1	0	2	0 3	
,   Sitting inactive, in a public space	 	O D	0 1	0   2	0 3	

Use the following scale to choose the most appropriate answer:
D - No chance
-	1 - Slight chance

.							3 - High chance	
:	Lying down to rest in the afternoon when circumstances permit	O D	0 1	0	2	0  3		
E"'	Sitting and talking to someone	O D	0  1	0	2	0  3		

{	2 - Moderate chance

.:,

Sitting  quietly  after a lunch without alcohol	O D		0 1	0	2	0 3	
As a passenger in a car for an hour without a break	O D	0 1	0	2	0 3	
In a car, while stopped for a few minutes in traffic		O D	0 1	0	2	0 3	

i
I
;JI
0

0SA-50 Screening Questionnair e - Patient must score 5 or more.

Total score:

fil Waist circumference (Measure at the level of the umbilicus)
.c
Male> 102cm IFemales> 88cm	 	O Yes (3 points)

l

Has your snoring ever bothered other people?
Has anyone noticed you stop breathing during your sleep? Are you aged 50 years or over?
Symptoms and medical condit ions

O  Yes   (3 points)
O  Yes (2points)

O Yes (2points) Total score:

0 Hypertension
0 Cardiac failure
0 Stroke / TIA Q COPD
Notes

0 Overweight O Pacemaker
O Type II Diabetes
0  Atrial fibrillation

0 Family history (OSA)
0 Clinical history
/optional, otracn notes to this referral}

For a refe rr al to be valid , please ensure the fo llow in g details are completed and SIGNED

R eferring Dr. name Prof Lauren Iverson	Practice name Avengers Hospital

Provi der no. 0785462W

AddressTCB Building FORTITUDE VALLEY NT 4006

Email support@geniesolutions.com.au

Phone1300 889 362

Fax 07 1234 5678

Referring
Dr. signature:	Referral date
O Communication via secure e-messaging preferred

Re sMe d.com.au	«' L ]1 ResMed L!d. 101\' <q□ 2019- 1

Awaken

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ResMed

Approved DVA Supplier

Providing CPAP equipment for eligible OVA clients.

Please send your referral to us by
Fax: 1800 317 339 or via secure messaging

For support or general inquires call:
1800 737 633 (ResMed) or Email: info@resmed.com.au

Q
ResMed store locations

New South Wales

Bella Vista

Sydney CB □

Bondi Junction Burwood Campbelltown Dee Why Gosford Kogarah Liverpool Macquarie Park Miranda Parramatta Newcastle
Surry Hills

Queensland
Cleveland Maroochydore Mermaid Beach Milton

ACT
Deakin
*Services may vary by store

Victoria
Ballarat Camberwell Collingwood Dandenong Essendon Geelong Malvern Mitcham Mornington Mt Waverley
Ringwood East

a
For more information, online bookings, more nearest ResMed store visit:
ResMed.com.au

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