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Refer a friend

Know a friend, relative, or co-worker who may be interested in this product? Take this opportunity to let them know.

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

Referring Doctor

Referring Doctor*

Phone*

Example: (649)845-0088

Date*

Example: 23/01/2010

Fax

Address

The Message.	Hi, You're receiving this email because {name} thinks the ResMed AirSense 10 Elite ANZ 4G would interest you. The AirSense 10 Elite is a premium fixed pressure device that has been designed to make therapy easy. With a built-in heated humidifier and no complicated settings or menus to navigate, simply press Start and you’re ready to go. And with wireless connectivity* built into your machine, your healthcare professional can stay more connected to your therapy progress than ever before. * Wireless communication depends on network availability Please note we are unable to supply machines purchased on-line from patients who have not had a sleep study here at NZRSI or are unable to provide us with a prescription from their clinician. For more information, please click Here Regards,
Bracketed text e.g {name} indicates details that will be completed by the system when you click the submit button.
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