WALK-IN SPIROMETRY LABORATORY (Tuesday-Friday) 0830-1200; 12:30-1600
NO APPOINTMENT REQUIRED (please bring referral form with you)
Gordon & Leslie Diamond Health Care Centre, 7th Floor (Corner of Oak & 12th) 2775 Laurel Street, Vancouver BC, V5Z 1M9 Telephone: 604.875.4324 Fax: 604.875.4695
* * If you are 15-18, please attend testing accompanied by an adult Anyone < 15 years can be referred to BC Children’s Hospital for testing
________________________________________________________________________ Date: PATIENT NAME: _________________________________________________
Address: ______________________________________________________________ ______________________________________________________________ Telephone: (H) ____________________ (W) _______________________________ PHN: ____________________________ DOB: _____________________________ Bronchodilators: Y/N Beta Blockers: Y/N Smoking History: Y/N if yes, # pack yrs. ____________________ Infectious Precautions: Y/N
REASON FOR REFERRAL (Presenting concern):
Tests Requested (Please check the boxes): Spirometry, Flow/Volume Loop, pre-bronchodilator Spirometry, Flow/Volume Loop, post-bronchodilator Skin testing (30 allergens), for trigger avoidance Oximetry – resting Oximetry – walking (3 min. or to tolerance) REFERRING PHYSICIAN: NAME (print): _______________________ Signature: __________________________ FAX #: ____________________________
MSP No: ___________ Telephone: ___________