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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 Respironics Dreamwear Full Face Mask would interest you. DreamWear Full face mask combines the innovative hose on the top of your head design with a full face cushion that prevents red marks, discomfort or irritation on the nose bridge along with improved comfort and more freedom of movement when sleeping. For more information, please click Here Regards,
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