Online Referral

Referral Form

(Must be completed by a medical practitioner)

    Appointments bookings 1300 112 404

    Email: admin@respact.com.au

    Fax: 02 5134 4816

    IMPORTANT : PRIOR TO TEST IF POSSIBLE DO NOT TAKE
    4 -6 hours prior to your appointment time: Ventolin, Bricanyl, Asmol or Airomir
    12 hours prior to your appointment time: Flixotide, Pulmicort, Qvar, Atrovent
    24 hours prior to your appointment time: Serevent, Oxis, Alvesco, Seretide, Symbicort,
    Trelegy 36 hours prior to appointment time: Onbrez, Brimica, Ultibro, Anoro, Brea
    36 - 48 hours prior to appointment time: Spiriva, Bretaris, Seebri, lncruse, Spiolto
    Note all medications may not be listed. If unsure contact RespACT

    Date

    Time

    Patient Name*

    DOB*

    Phone*

    Email*

    Address*

    Medicare

    Clinical Details (reason for test):

    Required Tests (please tick)

    Other

    Referring Doctor

    Name*

    Provider No*

    Address*

    Fax*

    Email*

    Date*


    Copies of report to be sent to:

    Name*

    Fax*

    Email*

    Other

    Locations

    Address
    Suite 14, Calvary Clinic
    40 Mary Potter Circuit Bruce, ACT 2617
    1300 112 404
    Address
    Unit 9, Francis Chambers
    40 Corinna Street Phillip, ACT 2606
    1300 112 404