Always striving for quality
care and outcomes
Lung Health is our
Expertise
Breathe Freely,
Enjoy life
A breath of fresh air
is all you need
Lung Health is our
Expertise
Helping you with
every breath
Value lung health,
we do!

Referral for Specialist Consultation

Please complete this form in its entirety, and send to us. The form can be either completed online and sent electronically, or downloaded and printed out for manual completion and returned to The Lung Health Clinic by email, post or fax.

* Please note that all information transmitted to our clinic via the website is encrypted and a dedicated email address is used to receive electronic communications.

To download this form for manual completion, please click here.

Fields marked with an * are required

SPECIALIST REFERRAL

PATIENT DETAILS
Address


REFERRING DOCTOR/STAMP
Address

Send directly to the Lung Health Clinic by clicking SEND