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 / 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 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 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