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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 AirMini Bedside Starter Kit F20 would interest you. Introducing AirMini - the world’s smallest CPAP device suitable for use at home or while you're away. Engineered to deliver the same quality of therapy you have grown to trust from ResMed, you will never need to choose between therapy performance and freedom again. AirMini features: Small, discreet and ultra portable Bedside friendly contemporary design Convenient therapy control directly from your smartphone with the AirMini App Waterless Humidification with HumidX™¹ 1. Currently available for nasal and nasal pillows mask users. Please phone (09) 638 5255 for more information. 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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