Lung Function Request Form

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RSDC Ferntree Gully
719 Burwood Hwy Ferntree Gully Vic 3156

RSDC Wantirna
Suite 2A, Knox Private Hosp 262 Mountain Hwy Wantirna Vic 3152

55 Whitehorse Rd Deepdene Vic 3103

Patient details:

Test requested:

Spirometry Pre +/- Post Broncholidator (all locations)
Gas Transfer (Ferntree gully and Knox)
MIP/MEP (Ferntree gully and Knox)
FeNO (all locations)
Lung Volumes (Plethysmography) (Ferntree gully)
Oxygen assessment (Apply for oxygen supplementation) (Knox)
6MWT (Knox)
Bronchial Provocation Test (mannitol) (Ferntree gully and Knox)
Exercise challenge test (Knox)
CPET (Cardiopulmonary exercise test) (Knox)

I confirm that the above information is complete and correct.