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Stop-Bang Questionnaire
Asthma Control Questionnaire
Vocal Cord Dysfunction Questionnaire
CONTACT US
Menu
HOME
SERVICES
DOCTORS
INFORMATION
FAQ
Health Professionals
Patients
Publications
Webinars & Seminars
BLOG
FORMS & REFERRALS
Appointment Request Form
Lung Function Request Form
Sleep Study Request Form
Medical Review Referral Form
Patient Registration Form
Medical History
Epworth Sleepiness Scale
Stop-Bang Questionnaire
Asthma Control Questionnaire
Vocal Cord Dysfunction Questionnaire
CONTACT US
Appointment
Forms
Patient
Registration Form
FORMS
Fill all required fields (★) to submit the form.
Full Name:
(Required)
★ Title
Mr
Mrs
Ms
Miss
Other
Prefix
First
Last
Preferred name:
Date of birth:
(Required)
DD slash MM slash YYYY
Mobile Number:
(Required)
Home Phone:
Address:
Email Address:
(Required)
Responsible Party:
(Required)
DVA (Gold/White)
Aged Pension
Workcover
TAC
N/A
Membership/Claim number:
Contact number:
Address:
Email address:
Next of Kin:
Name:
Address:
Contact number:
Relationship to patient:
Emergency contact:
Insurance Information:
Medicare number:
Your Ref no:
Name of Private Health Fund:
Expiry Date
Member Number:
Referrals:
General Practitioner:
(Required)
Referring Doctor:
RSDC doctors would like all the referrals to be sent no later than one day prior to the scheduled appointment. Specialist referrals are valid for 3 months and GP to specialist referrals are valid for 12 months. We recommend obtaining a a referral from your GP that will last for one year.
Information about Fees:
RSDC doctors do not bulk bill in their private rooms, however they do attend public clinics which will require a valid referral.
Payment in full is required on the day of the consultation.
For the details of RSDC fees please call our staff 1300773210.
There is an out-of-pocket cost for the Cardio Pulmonary Exercise Test and Home-Based Sleep Study for all patients.
Payment and Cancellation Policy:
In the event an appointment is cancelled with less than one business day notice, full consultation fee will be charged.
Confirm:
(Required)
Please note, if you see one of our doctors and they request a test (bloods, scans, ultrasounds, etc.), the results will be automatically sent to the computer and not seen by the doctors. You will have to make a separate appointment or see your GP for the results if needed.
(Required)
Confirm:
(Required)
I was informed and agreed to pay the costs associated with the treatment.
(Required)
Confirm:
(Required)
I have read and accept that I am responsible for having a valid referral and for any consultation fees.
(Required)