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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

Referring Physician/Healthcare Professional’s Name *

Profession *

Organisation *

Name of (Office) Contact *

(Office) Phone *

(Office) Fax *

(Office) Email Address *

Street Address *

State

Post Code

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.

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