. REQUEST FOR RESPIRATORY FUNCTION TESTING REFERRING DR DETAILS Requesting M.O. Provider Number Extra Copies To Result needed by Requesting M.O. signature Patient Details Surname Given name Address Phone DOB(mm/dd/yyyy) Sex Select Male Female Pager Number Date of request Patient Contact No Please Provide relevant clinical notes (including bronchodilator therapy) Does the patient have a communicable infection? eg TB, MRSA, VRE, multi-drug resistant Pseudomonas Yes No Please Specify Spirometry and Flow volume curves Pre and Post Bronchodilator Lung volumes Gas Transfer 6 minute walk test - Please Specify Air O2 1/min An appointment to see a Respiratory physican will be made to discuss the result. Please tick this box if an out patient appointment not needed
