Lung Function Smart Referral

Respiratory Service Referral

Patient Given Name (as per Medicare card) *

Patient Surname (as per Medicare Card) *

DOB *

Phone *

Address

Medicare

Ref

Exp

Additional Information, Relevant History and Medications:

Referring Doctor Name *

Provider Number *

Physician Phone *

Physician Fax

Referring Doctor Address *

Street address *

City *

State *

Postcode *

Date of Referral *

Request Urgency

Category 1 (Very Urgent- within 30 days)Category 2 (Urgent- within 3 months)Category 3 (Standard- within 12 months)

Duration of Referral

3 months (Specialist) 12 Months (GP) Indefinite

Location

Morwell GeelongVisiting Regional Clinic

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Signed: *

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Any other notes for the Medical Scientist or Doctor