VSC-BOOKINGS PAGE - Virtual Specialist Consults

Skip to content

CLOSE FORM

CLOSE FORM

CLOSE FORM

CLOSE FORM

CLOSE FORM

CLOSE FORM

CLOSE FORM

CLOSE FORM

CLOSE FORM

CLOSE FORM

CLOSE FORM

CLOSE FORM

Patient Details

Full Name *

DOB *

Street Address *

State

Post Code *

Email Address *

Mobile Number *

Medicare Number

Medicare Expiry Date

Number on card

Referral Reason *Chronic Obstructive Pulmonary DiseaseInterstitial Lung DiseaseOther Lung Disease

Patient is willing to participate in Virtual Pulmonary Rehabilitation *YesNo

Has the patient been admitted to hospital within the past 4-weeks due to a respiratory cause? *YesNo

Interpreter Required *YesNo

Is the patient currently on Oxygen? *YesNo

Interpreter Language

We cannot accept this patient currently

Referral Information

Referrer Details

Referring Physician/Healthcare Professional’s Name *

Profession *

Organisation *

Name of (Office) Contact *

(Office) Phone *

(Office) Fax *

(Office) Email Address *

Street Address *

State

Post Code

Regular GP Details

GP Name

GP Phone Number

Street Address

Post Code

Additional Files

Please email the most recent clinic notes or healthcare summary and RFT/imaging results to vvpr@nh.org.au, to enable referral processing.