Referral for Pulmonary Testing

Roy T. McKay, Ph.D. Laboratory Director 222 Piedmont Avenue (Medical Arts Building) Suite 3400, 3rd Floor, UC Physicians Cincinnati, OH 45219	Referral for Pulmonary Testing To Schedule an Appointment Call: 513/475-7720 Please fax this form to 513/475-7711 when making an appointment
Name of patient: __________________________________ Daytime Phone: ______________________ Diagnosis: _______________________________________

Please identify the service(s) you wish to have performed.

  Spirometry (FVC, FEV₁, FEF_25-75%, FEV₁/FVC%)

  Add Post-bronchodilator (routinely)

  Add Post-bronchodilator (only if airway obstruction is present)

  Add Methacholine Challenge study if baseline spirometry is normal

  Methacholine Challenge Testing

  Diffusion Study & Lung Volume Study (DLco & DL/Va, TLC & RV)

  Radiographic TLC (requires PA & lateral chest films)

  Maximum Voluntary Ventilation (MVV)

  Inspiratory Flow-Volume Loops

  Electronic Ambulatory Monitoring of FEV₁ & Peak Flow

  Trend Analysis for FVC & FEV₁ (call for details)

  Respirator Fit Testing (call and ask for fit test referral form)

Please note special concerns here: __________________________________________________________________________________

___________________________________________________________________________________

Send Report /Results To: (Please Print Clearly)

___________________________________________

___________________________________________

___________________________________________

___________________________________________

Phone: _____________________________   Send Report/Results by:

    Mail (results will be sent by U.S. Mail unless otherwise indicated.

    Fax to: ___________________________________

  A "No Show" fee will be charged unless prior notification is given.

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Please identify the service(s) you wish to have performed.
Spirometry (FVC, FEV₁, FEF_25-75%, FEV₁/FVC%)
	Add Post-bronchodilator (routinely)
	Add Post-bronchodilator (only if airway obstruction is present)
	Add Methacholine Challenge study if baseline spirometry is normal
Methacholine Challenge Testing
Diffusion Study & Lung Volume Study (DLco & DL/Va, TLC & RV)
Radiographic TLC (requires PA & lateral chest films)
Maximum Voluntary Ventilation (MVV)
Inspiratory Flow-Volume Loops
Electronic Ambulatory Monitoring of FEV₁ & Peak Flow
Trend Analysis for FVC & FEV₁ (call for details)
Respirator Fit Testing (call and ask for fit test referral form)
Please note special concerns here: __________________________________________________________________________________ ___________________________________________________________________________________

	Send Report /Results To: (Please Print Clearly) ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Phone: _____________________________	Send Report/Results by: Mail (results will be sent by U.S. Mail unless otherwise indicated. Fax to: ___________________________________ A "No Show" fee will be charged unless prior notification is given.

	Home page \| Directions \| Maps