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Ph:    02 6551 0771
Mob: 0455 583 399
Fax:  02 6551 0700

Mid North Coast Sleep Clinic

Consulting at:

  • Intalink Therapy Solutions, 5 Macquarie Street, Taree, NSW 2430
  • Macintosh Medical, 97-99 Macintosh, Streeet, Forster NSW 2428
  • Gloucester Medical Centre, 77-81 Denison Street, Gloucester NSW 2422

Postal Address:

  • PO Box 1127, Taree NSW 2430
  • Phone: 02 6551 0771
  • Fax: 02 6551 0700
  • Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

REFERRAL FORM

For bookings please fax completed form to 02 6551 0700 or email: This email address is being protected from spambots. You need JavaScript enabled to view it.

MID NORTH COAST SLEEP CLINIC

PHONE: 02 6551 0771 FAX: 02 6551 0700 MOBILE: 0455 583 399 EMAIL: This email address is being protected from spambots. You need JavaScript enabled to view it.

HOME SLEEP STUDY REFERRAL FORM

TO: ASSOCIATE PROFESSOR MICHAEL DODD,

All items marked with an asterisk (*) are required fields


 

**Patient must meet both of the below criteria to qualify for a Home Sleep Study**


 

How likely are you to fall asleep in the following situations?

Please score each activity using the following guide:

0 = would never doze
1 = slight chance of dozing
2 = moderate chance
3 = high chance of dozing

 

 

 

 


 

All Medicare subsidised studies must meet the approved criteria above, in accordance with Medicare item 12250. The assessment and appropriateness of home studies are overseen by a supervising sleep physician.

PLEASE SUBMIT THIS REFERRAL. Our Staff will contact the patient to book a convenient appointment.

 

Our Locations

Intalink Therapy Solutions 5 Macquarie Street, Taree, NSW 2430

Macintosh Medical 97-99 MacIntosh St, Forster NSW 2428

Gloucester Medical Centre 77-81 Denison Street, Gloucester, NSW 2422

Get In Touch

Phone: 02 6551 0771
Mobile: 0455 583 399 
Fax: 02 6551 0700
Email: admin@mncsleepclinic.com.au

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