Spirometry Referral



All fields marked with * are mandatory.

Date: *

Client / Patient details:

Surname :*
First Name: *
Date of Birth: *
Gender: *
Phone Number (Home / Work): *
Mobile Number:
Ethnicity: *
NHI: *
Community Service Card:
GP Name:*
GP Practice: *
Referred By:
Referring organisation/practice: *
Please Specify: *
Patient consent obtained for a referral to Asthma Waikato: *
Other relevant information: *
Reason for spirometry referral: *

Please note : Asthma Waikato will only accept referrals for spirometry testing from registered medical doctors. Please advise your patient which medications you wish them to cease (if any) prior to their test.

I confirm I am a registered medical doctor and I authorise Asthma Waikato and the technician there to administer 400mcgs of Ventolin or similar for the purposes of assessing post bronchodilator reversibility.

Address:

Find Address:
House No:
Floor/ Building:
Street :
Postal Code: *
Suburb/ Town: *
Region: *

Current Medications:

Medication Name:
Dosage:

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