Referral Form

Appointments bookings 1300 112 404

Email: admin@respact.com.au

Fax: 02 5134 4816

Unit 9, Francis Chambers, 40 Corinna St., Phillip ACT 2606Suite 14, Calvary Clinic, 40 Mary Potter Circuit Bruce,ACT 2617

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

Hours

Minutes

Patient Name

DOB

Phone

Address

Medicare

Clinical Details (reason for test):

Other

Referring Doctor

Copies of report to be sent to:

Name*

Name

Provider No

Fax