Respiratory Services Requisition Vancouver/Lower Mainland Obstructive Sleep Apnea (OSA) Screening and Treatment OSA Screening OSA Treatment
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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.