ReferralRespiratory | Cardiology

Label Here

Date:

Physician name:

Physician address:

Physician fax:

Physician phone: Prac ID:

Physician signature:

Is this an Urgent Request?Yes No

Copies to:

Referring Physician

Considered a valid prescription when signed by a physician

Patient Information

Please fax completed form to desired location. We will call the patient to book.

Clinical Notes:

Clinical History:

Pulmonary Function Testing:

Respiratory Assessment / Home Oxygen :

Sleep Study:

www.arcnetwork.ca

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Revision Date: 26/07/2019

Sleep Respiratory

SnoringHypertensionAsthma/COPD

Patient Aware of Referral?Yes No

Witnessed ApneaDiabetesGasping

Adult Pulmonary Consult

Adult Internal Medicine Consult

Full Pulmonary Function

Pre-post Spirometry

Home Oxygen Assessment- AADL ProtocolABG, 6 Minute Walk Test and PFT

Nocturnal Oximetry (fee applicable)

Arterial Blood GasKeep SpO2 >89% or > %

Lpm x Hr/day

Level III Sleep Study (no fee)

Level I Sleep Study (Polysomnography)(fee may be applicable)

Auto/Adjusted CPAP Therapy

If positive for sleep apnea per physician interpretation, initiate auto CPAP trial

cm H20 to cm H20

CPAP Therapy cm H20

BiPAP Therapy

IPAP EPAP RR TiMode: AVAPS ST Auto SV

ADVANCEDRESPIRATORY CAREN E T W O R K

LocationsCalgary NE#201, 3151 27 Street NE Calgary, AlbertaT1Y 0B4

T 403.235.4109F 403.235.4147

Calgary NW#250, 8730 Country Hills Blvd NW Calgary, AlbertaT3G 0E2

T 403.873.0891F 403.735.5163

Calgary SESunpark Professional Centre #225, 40 Sunpark Plaza SE Calgary, AlbertaT2X 3X7

T 403.873.0891F 403.873.1817

AirdrieTowerlane Medical Clinic Inside Shoppers Drug Mart Next to Staples#302, 505 Main Street S Airdrie, Alberta

T 403.873.0891F 403.735.5163

Red Deer#135, 4309 52 AvenueRed Deer, AlbertaT4N 6S4T 403.342.0494F 403.343.0304

Indications:

Otolaryngology (ENT)

Otolaryngology Consultation

Otitis MediaHearing LossVertigoSleep ApneaEpistaxisRhinosinusitis/Nasal ObstructionOther (please specify)

Oral Cavity LesionHoarsenessDysphagiaNeck MassTonsillitis

Adult CardiologyHolter MonitoringECG (Electrocardiogram)24 Hour Blood Pressure Monitor

- Only available at Red Deer -

AllergyAllergy Consult and Testing (tray fee applicable)

Consult onlyFood AllergyAllergy RhinitisAllergies, unspecifiedAtopic DermatitisCoughWheezingAsthmaHivesImmunotherapyOther (please specify)