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Lung Function Laboratory Referral Form

We are a Southern Cross Affiliated Provider


Sleep & Breathing (NZ) Limited
Ascot Office Park, Level 3, Building B
93-95 Ascot Avenue, Greenlane East
P O Box 109-409, Newmarket
Auckland 1149
Fax: 09 638 6022
Telephone: 09 638 5255
Email: referrals@nzrsi.health.nz
PATIENT'S DETAILS
Title*
First Name*
Surname*
Address*
NHI
Date of Birth*
Example: 29/03/1969
Phone (H)*
Example: (649)845-0088
Phone (W)
Example: (649)845-0088
Mobile
Example: (64)21-456789
TEST REQUESTED (Patients should withhold inhalers on the day of the test)
Spirometry with Flow/Volume loops
Pre and post bronchodilator
Lung volumes and flows with DLCO
Pre and post bronchodilator
Exercise VO2 assessment
6 minute walk test
Static mouth pressures (for muscle weakness)
Challenge testing
Tidal breathing (for Hyperventilation Syndrome)
Arterial blood gas (Home O2 assessment)
Hypoxic challenge for flying
Induced sputum
FENO

Clinical Details

Referring Doctor
Referring Doctor*
Phone*
Example: (649)845-0088
Date*
Example: 23/01/2010
Fax
Address
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Contact Us

 
PHONE                  09 638 5255
FREEPHONE         0800 895 120
FAX                        09 638 6022

referrals@nzrsi.health.nz

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LOCATION
Ascot Office Park 
Level 3, Building B
93-95 Ascot Avenue
Greenlane East
AUCKLAND 1051

Northcare
5 Home Place
Rosedale
Auckland
POSTAL ADDRESS
PO Box 109 409
Newmarket
Auckalnd 1149