Referral Form
Phone 1300 292 022 Fax 03 9318 4577
Email reception@lasv.com.au
Post 35 Summerhill Road, Footscray 3011

For an appointment please complete all details, including signature, and fax to 03 9318 4577. We will contact your patient within 24 hours.

PATIENT DETAILS
Surname <PtSurname>	Date of Birth <PtDoB>	 Given Name  <PtFirstName>	Sex   <PtSex>
Address   <PtPOAddress>		Postcode  <PtPOPostcode>	 Telephone <PtPhoneH>	Mobile <PtPhoneMob>		
Medicare No. <PtMCNo>     <PtMCExpiry>	Ref. <PtMCLine>    <PtPensionNo><PtPensionNo> <PtDVANo><PtDVACard>	
REFERRING DOCTOR DETAILS

Doctor Name <UsrName>    <UsrSurname>	Provider No. <DrProviderNo>		 Address  <DrAddress>		Postcode  <DrPostcode>	 Telephone  <DrPhone>	Fax  <DrFax>		 Signature 		Date  <TodaysDate>	 Clinical Notes: 			

Our Services
ALLERGY
• Allergy consultation
PREPARATION FOR ALLERGY TESTING
Please ensure that no antihistamines are taken for at least three days before the appointment. Nasal steroid sprays
(eg: Avamys, Dymista, Nasonex, Omnaris and Rhinocort) may be continued.

RESPIRATORY
•	Respiratory physician consultation
•	Spirometry/ TLCO (strike out if not required)
•	Lung volumes (plethysmography)
•	Bronchial provocation – Mannitol

PREPARATION FOR LUNG FUNCTION TESTS
•	No short term bronchodilators
to be used for 4 hours, unless required (eg: Ventolin, Atrovent, Asmol etc.)
•	No long term bronchodilators to
be used for 12 hours, unless required
(eg: Serevent, Oxis, Seretide, Symbicort etc.)
Mannitol provocation tests have specific preparation requirements that will be provided to the patient at the time of booking.

SLEEP MEDICINE
•	Diagnostic sleep study (see Note)
         Sleep physician consultation:
•	Pre-study
•	Post-study

Clinical Details
•	ESS score of 8 or more
•	STOP-BANG score of 3 or more
•	OSA-50 of 5 or more
•	Snoring
•	Daytime tiredness
•	Witnessed apnoeas
•	Hypertension
•	Atrial fibrillation
•	Diabetes mellitus
•	Heart disease
NOTE: This request includes referral to a qualified sleep physician, to provide a medical consultation, when the patient’s presentation is not in keeping with a high probability for symptomatic, moderate to severe obstructive sleep apnoea.

STOP-BANG SLEEP QUESTIONNAIRE 
(to be completed with patient)
Please answer all the questions     Yes	No
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?     Y/N	Do you often feel TIRED, fatigued, or sleepy during daytime?	                                              Y/N	Has anyone OBSERVED you stop breathing or choking during your sleep?                              Y/N       Do you have or are you being treated for high blood PRESSURE?                                                   Y/N	BMI more than 35kg/m2?                                 Y/N	AGE over 50 years old?	                               Y/N
NECK size large? ** (Males:43cm+ & Females:41cm+)                                              Y/N	GENDER: Male?                                              Y/N		   Total Score =>	

See reverse for a list of our clinic locations and where specific tests and services are available. For more information please visit www.lasv.com.au

See reverse for a list of our clinic locations and where specific tests and services are available. For more information please visit www.lasv.com.au

A STOP-BANG score of 4-8 identifies patients with high probability of moderate/severe OSA, and qualifies for Medicare Bulk-billing rebate	

EPWORTH SLEEPINESS SCALE QUESTIONNAIRE 
(to be completed with patient)
Use the following scale to choose the most appropriate number for each situation:
0 = would never doze    1 = slight chance of dozing   2 = moderate chance of    3 = high chance of dozing
      dozing
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? 
This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently try to work out how they would have affected you.
Situation (It is important that you answer each question as best you can)	
•	Chance of Dozing (0-3)	
•	Sitting and reading	 
•	Watching TV		
•	Sitting, inactive in a public place (e.g. a theatre or a meeting)	
•	As a passenger in a car for an hour without a break		
•	Lying down to rest in the afternoon when circumstances permit	
•	Sitting and talking to someone		
•	Sitting quietly after a lunch without alcohol	
•	In a car, while stopped for a few minutes in the traffic		
Total Score:	
Score Result:
0 – 7 = Normal
8 – 24 = Abnormal (qualifies for Medicare Bulk-billing rebate

Phone 1300 292 022 Fax 03 9318 4577
Email reception@lasv.com.au
Post 35 Summerhill Road, Footscray 3011

OUR LOCATIONS		PHYSICIAN CONSULT	SLEEP STUDY	LUNG FUNCTION	ALLERGY CONSULT	
Bayside / Peninsula	
FRANKSTON	Peninsula Private Hospital, Suite 7, 525 McClelland Drive, 3199	•	•	•		
PATTERSON LAKES	Bayside Specialist Centre, Suite 29, Level 1, 21 Thompson Road, 3197	•	•	•		
 Eastern							
BOX HILL	Box Hill Consulting Rooms, Suite 1, 28–32 Arnold Street, 3128	•	•			
 South Eastern / South Gippsland		
FOSTER	Foster Medical Centre (Telehealth), 97 Station Road, 3960	•	•	•	•	
LEONGATHA	Leongatha Hospital, 6 Koonwarra Road, 3953	•	•	•	•	
HAWTHORN EAST
MALVERN	Level 2, 141 Camberwell Road
Cabrini Medical Centre, Suite 32, 183 Wattletree Road, 3144	•
•	•
•	•
•	•
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EAST MALVERN	Central Park Specilaist Centre, 389 Wattletree Road, 3145	•	•	•		
SPRINGVALE	Springvale Suites, 8 Windsor Avenue, Springvale, 3171	•	•			
 Northern							
BUNDOORA	Northside Specialist Clinic, Suite 209, 12 Ormond Boulevard, 3083	•	•			
SEYMOUR	Seymour Medical Clinic (Telehealth), 30–32 Anzac Avenue, 3660	•	•			
WALLAN	Nexus Primary Health, 7–11 High Street, 3756	•	•			
 Western							
BACCHUS MARSH	Bacchus Marsh Eye Clinic, 16 Grant Street, 3340	•	•			
BRUNSWICK	Brunswick Private Hospital Consulting Suites, 82 Moreland Road, 3056	•	•			
FLEMINGTON	Flemington Consulting Rooms, Suite 31, 320–380 Epsom Road, 3031	•		•		
FOOTSCRAY	Footscray Consulting Rooms, 35 Summerhill Road, 3011	•	•	•	•	
GISBORNE	Gisborne Medical Centre, 16 Brantome Street, 3437	•	•			
NIDDRIE	North West Specialist Centre, Suite 6, Level 1, 326 Keilor Road, 3042	•	•	•	•	
SEBASTOPOL	Sebastopol Consulting Rooms (Telehealth), 49–51 Albert Street, 3356	•	•			
SYDENHAM	Sydenham Specialist Suites, 574 Melton Highway, 3037	•	•	•		
SUNBURY	Sunbury Suites, 17–19 Horne Street, 3429	•		•		
WERRIBEE	Wyndham Private Consulting Rooms, Level 1, 242 Hoppers Lane, 3030	•	•	•		
WILLIAMSTOWN	Williamstown Consulting Rooms, 110 Douglas Parade, 3016	•