CPAP
Therapy Prescription

1300 27 27 63
cpapnetwork.com.au

Patient Details		
Name:			
Address: 		Postcode:	
Phone:		DOB: 		

 	

Mask Type	
Brand	Style	Mask Name	Chinstrap	
Resmed FCP
Lowenstein Philips Other	Nasal Full Face
Pillow/Cradle	Size
Or as per best fit	Yes No	

AHI:	 Clinical Details: 	 Request for:  CPAP Trial  CPAP Purchase  Review of CPAP Treatment

CPAP Settings	
Set Pressure	cmH2O	Ramp Start:	cmH2O	Ramp Time:	
Adjust Pressure	From:	cmH2O	To:	cmH2O		

APAP Settings	
Autoset Titration	Default: 4 to 20cmH2O	Ramp Time:	
Autoset Pressures	Min:	cmH2O
Max:	cmH2O	Ramp Time:	
 I would like a copy of a progress report emailed to me Comments

Referring Doctor/Physician Details		
Name:		Practice Name: 		
Address: 		Postcode: 		
Phone: 		Fax: 		
Email: 		
Signature: 		Date: 		
Please fax this referral to 03 9739 5672 OR email to hss@cpapnetwork.com.au OR the patient can contact one of our convenient CPAP Network clinics over the page

CPAP Network clinics conveniently located at:

 Lilydale

283 Main Street
 F: 9739 5672
E: lilydale@cpapnetwork.com.au

 Cranbourne

4/78 High Street (enter via Bakewell St)
 F: 5996 8660
E: cranbourne@cpapnetwork.com.au

 Belgrave

1639 Burwood Highway
 F: 9752 6012
E: belgrave@cpapnetwork.com.au

 Boronia

157 Scoresby Road
 F: 9839 3378
E: boronia@cpapnetwork.com.au

 Mornington

Shop 3/193 Main Street
 F: 5990 5880
E: mornington@cpapnetwork.com.au

 Clayton

1344 Centre Rd
 F: 9253 3950
E: clayton@cpapnetwork.com.au

 Heidelberg

119 Burgundy Street
 F: 9458 3320
E: heidelberg@cpapnetwork.com.au

 Balwyn North

297-301 Doncaster Road
 F: 9857 9244
E: balwyn@cpapnetwork.com.au

 Preston
Preston Sleep Apnoea Centre
348 High Street
P: 8470 5200 F: 8470 5299
E: preston@cpapnetwork.com.au

  

1300 27 27 63	cpapnetwork.com.au