RESPIRATORY AND LABORATORY CONSULTATION REQUEST

PATIENT DETAILS
Surname:						Given Name:
Address:
Date of Birth:						Telephone:

CLINICAL NOTES / REASON FOR REFERRAL
____________________________________________________________________________________________________________________________________________________________________

TESTS REQUIRED / RESPIRATORY FUNCTION TESTS
☐ Spirometry
☐ Transfer Factor
☐ Plethysmographic Lung Volumes
☐ FeNO
☐ Bronchial Provocation Tests (Mannitol)
☐ Maximal Respiratory Pressures
CONSULTATION
☐ Consultation with Specialist Physician

REQUESTING DOCTOR
Name:								Provider Number:
Address:							Phone/Fax:
Signature:							Date:
Copies to:

IMPORTANT:
Please see detailed respiratory test preparation instructions and medication withholding requirements.

Products To Be Avoided Prior To Testing
	Time To Be Avoided Prior To Testing
(Unless essential)	
	Routine Testing	Bronchial Provocation Testing	
Short-acting bronchodilator
(Ventolin, Bricanyl, Atrovent, Asmol)	6 Hours	8 Hours	
LAMA (Spiriva, Genuair, Seebri, Incruze, Anoro)	12 Hours	24 Hours	
LABA (Serevent, Foradile, Oxis, Onbrez, Anoro)	24 Hours	24 Hours	
Combination steroid/LABA (Seretide, Symbicort, Flutiform, Ellipta)	24 Hours	24 Hours	
Antihistamine (Zyrtec, Telfast, Claratyne etc.)	N/A	72 Hours	
Caffeine	N/A	Day of Test	
Theophylline	N/A	24 Hours	

Do not stop any medication that is essential for your safety without medical advice.

MAIN LAB LOCATION
226 Burgundy St
Heidelberg VIC 3084