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: <<Miscellaneous:Date>>        
Patient Details:
Surname: <<Patient Demographics:Surname>>	Ph:  <<Patient Demographics:Phone (Home)>>  Mob: <<Patient Demographics:Phone (Mobile)>>	
Given Name: <<Patient Demographics:First Name>>	Medicare No: <<Patient Demographics:Medicare Number>> <<Patient Demographics:Medicare Expiry Date>>	
DOB:  <<Patient Demographics:DOB>>	DVA#:  <<Patient Demographics:DVA Number>> 	
Address: <<Patient Demographics:Full Address>>		
	DVA		Pensioner		Healthcare card	

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

Indications:
<<Indications>>

Special Instructions:
<<Special Instructions>>

Referring Doctor:
Name: <<Doctor:Name>>	Provider #: <<Doctor:Provider Number>>	
Report Preference:
	
Email	
	
Fax	
	
Post	
	
Healthlink	

	Phone: <<Doctor:Phone>>
Fax: <<Doctor:Fax>>
Email: <<Doctor:E-mail>>	

Doctors Signature: 

 _________________________________

Date: <<Miscellaneous:Date>>	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.