St Vincent's Private Hospital, 240 Hoppers Lane, Werribee 3030 Ph: 03 9191 4043    Fax: 03 9017 8964    E: info@tcspm.com

WERRIBEE LUNG FUNCTION LABORATORY                                     Date: <TodaysDate>         
Patient Details:

Surname: <PtSurname>	Ph:  <PtPhoneH>   Mob: <PtPhoneMob>	
Given Name: <PtFirstName>	Medicare No: <PtMCNo> <PtMCLine> <PtMCExpiry>	
DOB:  <PtDoB>	DVA Card Type:  <PtDVACard> DVA#: <PtDVANo>	
Address: <PtAddress>		
<DVA> DVA	<Pensioner> Pensioner	<Healthcare card> Healthcare card	

Diagnostic Test: 
<Spirometry/DLCO> Spirometry/DLCO	<Bronchial Provocation Testing> Bronchial Provocation Testing	
<Six minute walk test/O2 Assessment> Six minute walk test/O2 Assessment	<Lung Volumes (plethysmography)> Lung Volumes (plethysmography)	
<FeNO (exhaled nitic oxide)> FeNO (exhaled nitic oxide)	<MIPS/MEPS> MIPS/MEPS	
<FOT (airwave oscillometry)> FOT (airwave oscillometry)	<Other> Other 
<Other tests required (if applicable):>	
<Consultation required> Consultation required		
Indications:
<Indications>

Special Instructions:
<Special Instructions>

Referring Doctor:
Name: <DrName>	Provider #: <DrProviderNo>	
Address: <DrAddress>
	Phone: <DrPhone>
Fax: <DrFax>
Email: <DrEmail>	
Report Preference: <Report Preference:>	 	

Doctors Signature: 

 _________________________________	

Date: <TodaysDate>	IMPORTANT
Before testing if possible avoid taking Ventolin /  Asmol / Bricanyl for at least 4 hours prior.
Avoid ICS, LABA and LAMA medications  (e.g. Spiriva, Seretide, Symbicort, Breo, Spiolto, Flutiform and others) for 12 hours prior to testing.