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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
Title*
First Name*
Surname*
Address*
NHI
Date of Birth*
Example: 29/03/1969
Phone (H)*
Example: (649)845-0088
Phone (W)
Example: (649)845-0088
Mobile
Example: (64)21-456789
REFERRAL REQUESTED

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.

TYPE OF INVESTIGATION

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
Epworth sleepiness score = ___/24
REFERRING DOCTOR
Referring Doctor*
Date*
Example: 23/01/2010
Phone*
Example: (649)845-0088
Fax
Address
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Contact Us

 
PHONE                  09 638 5255
FREEPHONE         0800 895 120
FAX                        09 638 6022

referrals@nzrsi.health.nz

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LOCATION
Ascot Office Park 
Level 3, Building B
93-95 Ascot Avenue
Greenlane East
AUCKLAND 1051

Northcare
5 Home Place
Rosedale
Auckland
POSTAL ADDRESS
PO Box 109 409
Newmarket
Auckalnd 1149