Free shipping for all orders over $79
View Favourites

Sleep Laboratory Referral Form

Sleep Questionnaire

Please fill out the referral form below:

We are a Southern Cross Affiliated Provider
Sleep & Breathing (NZ) Limited
Ascot Office Park, Level 3, Building B
93-95 Ascot Avenue, Greenlane East
P O Box 109-409, Newmarket
Auckland 1149
Fax: 09 638 6022
Telephone: 09 638 5255
Email: referrals@nzrsi.health.nz

PATIENT'S DETAILS
  • Example: 29/03/1969
  • Example: (649)845-0088
  • Example: (649)845-0088
  • Example: (64)21-456789
REFERRAL REQUESTED
  • Return to see referrer with reported test result for discussion of result and treatment options, or the need for further investigations.
    Pre-test Sleep Specialist opinion and discussion of investigation and treatment options.
    Post-test Sleep Specialist opinion and discussion of treatment options.
    Note: Patients with tonsillar hypertrophy, anatomical nasal obstruction, or mucosal nasal obstruction (not responding to medical therapy) should first be seen by an Otolaryngologist.
  • Screening Respiratory Study
    Complex Respiratory Study
    Diagnostic Polysomnography (PSG)
    Split-Night Polysomnography (PSG)
    CPAP Pressure Setting Study
    MSLT with prior PSG
    MWT with prior PSG
    Actigraphy / Sleep Diary
    Infrared Video Monitoring (home)
CLINICAL DETAILS
REFERRING DOCTOR
  • Example: 23/01/2010
  • Example: (649)845-0088
In order to assist us in reducing spam, please type the characters you see:

Thank you for subscribing!

The owner has been notified and will contact you via email.

Let's keep you updated!

Please provide your name and email so the owner can contact you.