REFERRAL FORM 
Please send your referral to us by Fax: 1800 317 339 or via secure messaging 
Our staff will contact the patient to book an appointment. Patients: Please bring this referral to your appointment.	

Full name: <<Patient Demographics:Full Name>>		 DOB: <<Patient Demographics:DOB>>	

Email:<<Patient Demographics:E-mail>>		Phone/Mob:<<Patient Demographics:Phone (Mobile)>>		Commercial drivers licence		

	Yes		

	No	

Request for a Referral (Please mark appropriate options)

	Home sleep study - This referral covers both a Home Sleep Study, and if required, sleep physician consultation	

	CPAP/APAP trial for the treatment of sleep apnea	

	Mandibular advancement oral device for the treatment of snoring and sleep apnea	

	CPAP therapy review (pressure, compliance, mask review & full equipment check) 	

	Supply of DVA approved equipment and services 	

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

Both ESS and OSA-50 questionnaires must be completed	

ESS Questionnaire - Patient must score 8 or more.	

How likely are you to doze off (fall asleep) in the following situations?

Sitting and reading	

	
0	

	
1	

	
2	

	
3	

Watching television	

	
0	

	
1	

	
2	

	
3	

Sitting inactive, in a public space	

	
0	

	
1	

	
2	

	
3	

Lying down to rest in the afternoon when circumstances permit	

	
0	

	
1	

	
2	

	
3	

Sitting and talking to someone	

	
0	

	
1	

	
2	

	
3	

Sitting quietly after a lunch without alcohol	

	
0	

	
1	

	
2	

	
3	

As a passenger in a car for an hour without a break	

	
0	

	
1	

	
2	

	
3	

In a car, while stopped for a few minutes in traffic	

	
0	

	
1	

	
2	

	
3	

	Use the following scale
to choose the most
appropriate answer:

0 - No chance
1 - Slight chance
2 - Moderate chance
3 - High chance

Total score:	

OSA-50 Screening Questionnaire - Patient must score 5 or more.	

Waist circumference (Measure at the level of the umbilicus)
Male > 102cm | Females > 88cm	

	
Yes (3 points)	

Has your snoring ever bothered other people?	

	
Yes (3 points)	

Has anyone noticed you stop breathing during your sleep? 	

	
Yes (2 points)	

Are you aged 50 years or over?	

	
Yes (2 points)	

Total score:	

Symptoms and medical conditions	

	Hypertension		

	Overweight		

	Family history (OSA)	

	Cardiac failure		

	Pacemaker		

	Clinical history	

	Stroke / TIA		

	Type II Diabetes		(optional, attach notes to this referral)	

	COPD 		

	Atrial fibrillation			

Notes		

For a referral to be valid, please ensure the following details are completed and SIGNED	

Referring Dr. name: <<Doctor:Name>>		Practice name: <<Practice:Name>>	
Provider no: <<Doctor:Provider Number>>		Address:<<Practice:Address>>	
Email: <<Doctor:E-mail>>		Phone:<<Practice:Phone>>		Fax: <<Practice:Fax>>	

Referring  
Dr.  signature:	
Referral date	 
<<Patient Demographics:Referral Date>>	

	

	Communication via secure e-messaging preferred	

ResMed.com.au		                                         © 2019 ResMed Ltd. 10111596 2019-11	

		

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ResMed store locations
New South Wales

Bella Vista
Sydney CBD
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Burwood
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Liverpool
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ACT
Deakin

*Services may vary store by store	
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Victoria

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

Approved DVA Supplier

Providing CPAP equipment for
eligible DVA 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	

	

	

For more information, online bookings, more sleep related products or to find your
nearest ResMed store visit:	

ResMed.com.au