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Dr Ali Aminazad

MD, FRACP, FCCP, MClinResMeth Respiratory and Sleep Physician Teaching Associate Monash University

Dr Timothy Cheung

B.Pharm (Hons), MBBS, FRACP Specialist Respiratory and Sleep Physician

Dr Chuan Foo

MBBS (Hons), FRACP Specialist Respiratory and Sleep Physician

Dr Shahab Makki

FRACP Specialist Respiratory and Sleep Physician

Dr Sadie Porsa

MD, FRACP Respiratory and Sleep physician
Information

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Forms & Referrals

For Doctors

Medical Review Referral Form

Home-Based Sleep Study Request Form

Lung Function Request Form

Smoke Cessation Clinic Referral Form

Download Centre

LCSP Referral Form

For Patients

Vocal Cord Dysfunction Questionnaire (VCD-Q)

Epworth Sleepiness Scale

Patient Registration Form

Asthma Control Questionnaire Form

STOP-BANG Sleep Apnea Questionnaire

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Feedback Form
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Home

Services

Information

Doctors

Forms & Referrals

Media & Resources

Contact Us

Health Professionals

Patients

FAQ

Publications

For Doctors

Medical Review Referral Form

Home-Based Sleep Study Request Form

Lung Function Request Form

Smoke Cessation Clinic Referral Form

Download Centre

For Patients

Vocal Cord Dysfunction Questionnaire (VCD-Q)

Epworth Sleepiness Scale

Patient Registration Form

Asthma Control Questionnaire Form

STOP-BANG Sleep Apnea Questionnaire

Medical History

Feedback Form

Blog

Webinars & Seminars

Feedback Form

LCSP Referral Form

Download PDF Form

Fill all required fields (★) to submit the form.

Patient details:

Full Name:(Required)

Prefix First Last

Preferred name:

Date of birth:(Required)

DD slash MM slash YYYY

Mobile Number:(Required)

Home Phone:

Address:

Email address(Required)

Please choose your preferred location:

Clinic:(Required)

RSDC Ferntree Gully
719 Burwood Hwy, Ferntree Gully VIC 3156

RSDC Epworth Camberwell
Suite 2 Epworth Camberwell, 888 Toorak Rd, Camberwell VIC 3124

RSDC Knox
Suite 2a Knox Private Hospital, 262 Mountain Hwy, Wantirna VIC 3152

RSDC Balwyn North
345 Doncaster Rd, Balwyn North Vic 3104

RSDC Richmond
2a, Bridge Rd, Richmond Vic 3121

Diagnostic Request

Diagnostic Services Requested(Required)

Low Dose non contrast CT Scan of Chest for Lung Cancer Screening (MBS Item Number 57410)

Follow-up Low Dose non contrast CT Scan of Chest for Lung Cancer Screening (MBS Item Number 57413)

📋

MBS Item Numbers - NLCSP

The MBS item numbers for the National Lung Cancer Screening Program (NLCSP) are:

57410

Initial low-dose CT scan

57413

Follow-up/interval scans

Important: These items are mandatory bulk-billing and exempt from certain CT fee adjustments.

Referral Details

Reason for Referral and Clinical History(Required)

Patient meets criteria for LCSP

I consent to my CT Scan findings be discussed in Multi-Disciplinary Meeting (MDM), if it was thought to be necessary and the results be communicated with my referring doctor

Referring Practitioner's Details

Practitioner's Name

Provider Number

CC

To be Filled by Patient

Age: 50-70 years old?

Yes

No

Any Symptoms?

Yes

No

Symptoms:(Required)

Breathlessness

Cough

Phlegm

Chest pain or discomfort

Wheeze

Weight loss

Others

Others (include):(Required)

Current Smoker?

Yes

No

If you stopped smoking, did you stop less than 10 years ago:

Yes

No

Packsmeter (Pack-Years):

📊 Please refer to the Pack Years calculator below:

🔗 Calculate Pack Years

Have you had a CT Scan of chest within last 12 months?

Yes

No

Confirm:(Required)

I consent to my CT Scan findings be discussed in Multi-Disciplinary Meeting (MDM), if it was thought to be necessary and the results be communicated with my referring doctor.(Required)

Respiratory Sleep Disorder Centre

Contact Us

1300 773 210 (RSDC10)
0418 323 025
admin@rsdc.au
719 Burwood Hwy, Ferntree Gully VIC 3156

Support 24/7

Branches

Ferntree Gully
Knox
Balwyn North
Richmond
Camberwell

RSDC

FAQ
Services
Doctors
Contact Us

Dr Ali Aminazad

Dr Timothy Cheung

Dr Chuan Foo

Dr Shahab Makki

Dr Sadie Porsa

Health Professionals

Patients

FAQ

Publications

Gp Education Events

For Doctors

Medical Review Referral Form

Home-Based Sleep Study Request Form

Lung Function Request Form

Smoke Cessation Clinic Referral Form

Download Centre

LCSP Referral Form

For Patients

Vocal Cord Dysfunction Questionnaire (VCD-Q)

Epworth Sleepiness Scale

Patient Registration Form

Asthma Control Questionnaire Form

STOP-BANG Sleep Apnea Questionnaire

Medical History

Feedback Form

Webinars & Seminars

Blog

Videos

News

LCSP Referral Form

Patient details:

Please choose your preferred location:

Diagnostic Request

MBS Item Numbers - NLCSP

Referral Details

Referring Practitioner's Details

To be Filled by Patient