NARINDER - Referral Form Child

REFERRAL FORM - CHILD

Click here for adult referral form
Referral to:

Professor Narinder SinghDr Murray SmithDr Dakshika GunaratneDr Tesuven NaiduThe first available ENT specialist
PATIENT DETAILS
Full name of child

First NameLast Name
Date of Birth

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

Nasal obstruction / Blocked noseAdenoid facies / dark under eyesMouth BreathingLarge tonsilsSnoring / noisy breathingAllergic rhinits / Hayfever
Other Related Symptoms

Bruxism / Teeth grinding / ClenchingWhite (Dry) patches on teethOrthodonotic issuesNight sweatsBed wettingEar/ Hearing/ vertigoNeck lump/ massHoarse voiceThroat problems/ swallowingOther
Clinical Notes
INVESTIGATIONS (Optional)
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)Hearing test (Audiogram, Tympanogram)CT PTB (Petrous temporal bones)MRI Head/ IAMs
If results are available, upload here or email results to: contact@ents.com.au
REFERRING DOCTOR
Name
Provider Number
Email*
Telephone
Fax
Address
Signature

Clear
Date Submitted

DayMonthYear
Date
Should be Empty:

REFERRAL FORM - CHILD