NARINDER - Referral Form Adult

REFERRAL FORM - ADULT

Click here for children's referral form
Referral to:*

Professor Narinder Singh (Nose & Sinus and Snoring ONLY, adults and children)Dr Murray Smith (Head & Neck lumps, Thyroid, Voice, General ENT, adults and children)Dr Dakshika Gunaratne (Nose & Sinus, Skull base, General ENT, adults and children)Dr Tesuven Naidu (Ear, Hearing, Balance, General ENT, adults and children)The first available ENT specialist
PATIENT DETAILS
Full Name

First NameLast Name
Date of Birth

DayMonthYear
Mobile / Daytime Contact No.
Email
Address
Street, Suburb, State, Postcode
Assessment Requested

Nasal obstruction/ Blocked noseNasal allergySinus problemsRhinoplastySnoringTonsils/ Adenoids/ GrommetsEar/ Hearing/ tinnitus/ vertigoNeck lump/ massHoarse voiceThroat problems/ swallowing
Clinical Notes
REFERRING DOCTOR'S DETAILS
Name
Provider Number
Email*
Address
Telephone
Fax
Please list any investigations that have been done

CT or CBCT of nose and sinusesSleep studyAllergy tests ie Skin Prick Tests OR Blood Tests (RAST - Specific IgE)CT PTB (Petrous temporal bones)MRI Head/ IAMsHearing test (Audiogram, Tympanogram)
If results are available, upload here or email results to: contact@ents.com.au
Signature
Date Submitted

DayMonthYear
Date
Should be Empty:

REFERRAL FORM - ADULT