Lung Function Referral Forms - Southwest Pulmonary & Sleep Centre

Lung Function Referral Forms

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Patient Name

TEST Healthlink Date

Date of Birth

Address

Address Line 1

City

State / Province / Region

Postal Code

Phone

Smoking History:

Current
Ex-smoker
Never

Tests Required

Spirometry (Pre & Post Bronchodilator)
Lung Volumes
Diffusion Capacity
Exhaled Nitric Oxide (FeNo)
Mannitol Challenge Test (Bronchial Provocation Test)
MIPs & MEPs (Respiratory Muscle Function Tests)

Please withhold any puffers on the day of testing – See instructions on the reverse side of page

Referrer Details

Doctor

Provider No.

Address

Address Line 1

City

State / Province / Region

Postal Code

Phone

Healthlink EDI

LUNG FUNCTION TEST INSTRUCTIONS

Please read the following specific instructions to prepare for your lung function test:

All patients are asked to refrain from the following before their test –

• Smoking (1 hour)
• Performing vigorous exercise (1 hour)
• Consuming alcohol or caffeinated drinks (4 hours)

Suite 2.12, 90 Podium Way, Oran Park New South Wales 2570, Australia

Get in touch

Call : (02) 4607 5010

Facsimile

Fax : (02) 4607 5011

reception@swcpc.com.au

Company

Opening Hours

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