Name: DOB: PHN: Address: Date results required by: ______City: Complete and fax to 1-888-310-1441 We will contact the patient Phone:
Respiratory Services Requisition Vancouver/Lower Mainland Obstructive Sleep Apnea (OSA) Screening and Treatment OSA Screening OSA Treatment
Level III Multi-Channel If Positive Proceed to Auto CPAP Trial Home Sleep Study (Standard pressure range 6 to 16 cm H2O) Includes Overnight Oximetry and Sleep Specialist Interpretation
*As per AASM and CTS Guidelines, all Level III studies include sleep specialist interpretation CPAP/Bi-Level Therapy Prescription
CPAP: ______H2O
Auto-Titrating CPAP: Pressure Range ______to ______cmH20 Bi-Level: IPAP ______EPAP ______Rate ______Other - Please Specify: ______
Home Oxygen Assessment and Therapy
Home Oxygen Assessment (stable patients only) Home Oxygen Therapy Note: May include oximetry at rest, exertion and nocturnal Oxygen prescription ______LPM ______Hours/Day If oxygen prescription varies Rest ______LPM Exertion ______LPM Nocturnal ______LPM 24 Hour Blood Pressure Monitoring
Ambulatory 24 Hour Blood Pressure Monitoring - A nominal fee will be charged to the patient for this service
Reason for referral: ______Primary Diagnosis: ______Notes: ______
Date Ordering Physician Fax # Phone # Signature
Vancouver Surrey Langley Abbotsford 200 - 1847 W Broadway 11 - 15243 91st Ave 1 - 20133 102 Ave 204A - 32900 South Fraser Way
Phone 604-526-0208 • Toll Free Phone 1-888-310-1444 • Fax 1-888-310-1441 www.medprorespiratory.com OFFICE LOCATIONS
W 2th AVE 96 AVE 152 ST 148 ST GRANVILLE ST W 3th AVE
BURRARD ST FRASER HIGHWAY CYPRESS ST W 4th AVE 144 ST
W 5th AVE GRANVILLE VANCOUVER LOOP PARK 92 AVE W 6th AVE PINE ST FIR ST HEMLOCK ST 91 AVE W 7th AVE
FRASER HIGHWAY W 8th AVE SURREY
WEST BROADWAY 88 AVE
Vancouver Surrey 200 - 1847 W Broadway 11 - 15243 91st Ave 604-526-0208 604-526-0208
TO GOLDEN EARS BRIDGE
102 AVE SOUTH FRASER WAY GEORGE FERGUSON WAY
100 AVE SEVENOAKS MALL OLD YALE RD BOURQUIN CRES LANGLEY SOUTH FRASER WAY 199A ST GOLDEN EARS WAY 201 ST
PEARDONVILLE RD
MILL LAKE PARK 96 AVE 96 AVE
192 ST WARE ST WARE
200 ST BEVAN AVE 204 ST 208 ST 216 ST MARSHALL RD
ABBOTSFORD REGIONAL ROAD McCALLUM HOSPITAL ABBOTSFORD 88 AVE 88 AVE
Langley Abbotsford 1 - 20133 102 Ave 204A - 32900 South Fraser Way HEAD OFFICE SEVEN OAKS MALL 604-526-0208 604-864-0298
Phone 604-526-0208 • Toll Free Phone 1-888-310-1444 • Fax 1-888-310-1441 www.medprorespiratory.com