LHR Patient Referral Form

Tel:519-434-0730 Fax:519-434-2943
190 Wortley Rd, Suite LL1, London, ON N6C 4Y7


Health Number: Version: Date of Birth:
Last Name: First Name:
Phone Number: - ext Address:
City: Postal Code:

Treatment:
Home Oxygen: Medical Devices: Services:
Assessment Aerosol Compressor PFT
Set Up CPAP cm H2O Nocturnal Oximetry
Flow @ lpm Suction Equipment
SaO2>92% Aerochamber/MDI
With Exertion        
Nocturnally        
Palliative        

Requistioning Physician/Practitioner:

Physician/Practioner Number:

Patient Diagnosis:
Asthma Cor Pulmonale Pulmonary Fibrosis
CHF Emphysema
COPD CA

Comments:

Physician Signature:
Check this box to authorize physicians signature.
Note: By checking this box, I the physician, am authorizing the prescription in lieu of an actual signature for this electronic form.