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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 F&P Brevida Diffuser would interest you. F&P Brevida™ Diffuser Genuine replacement diffuser – minimises noise and air draft. Washable design: Easy to clean and reuse. Reduces exhaust noise: Disperses air gently away from you and your partner. Simple to fit: Clicks easily into your Brevida elbow. Recommended replacement: Every 3 months, or sooner if damaged. For more information, please click Here Regards,
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