COMMUNITY RESPIRATORY SERVICES REFERRAL
HOPE Clinic Appointment Date:
Appointment Time:
Client Name: Diagnosis:
PHN:
Date of Birth: 		Last Hospital Admission Date:
Hospital:
Address:
City:
Postal Code:
Phone:
Alternate Contact:
Relationship:
Phone:
 Family Physician:
Phone: Fax:
Nurse Practitioner:
Phone: Fax:
Specialist:
Phone: Fax:
Reason for Referral: Date:
                Respiratory (COPD) Education
                - Diagnosis of COPD confirmed by Pulmonary Function Test (PFT) or Spirometry.
                - Client agrees to participate in the education process.
                - Client cannot present with dementia or cognitive disorder
                Pre and Post Spirometry
                Contraindications:*Postpone if one of these contraindications is present*
                    None
                    Heart Attack/Stroke (1 month)       Chest Pain       High Blood Pressure       Tuberculosis
                    Recent Surgery (eye, chest, abdomen)       CHF       Pleurisy       Recent Pneumothorax
                   Cold or Flu (1 month)     Hemoptysis       Known aneurysm (cerebral, aortic, or thoracic)
                   Pulmonary Embolism      Chest Injury
Indication for Spirometry Testing:
*Physician agrees to order of 4 puffs of Salbutamol with order for pre and post spirometry
Referred by:      Physician     NP     RRT     RN     Other
Signature:
“Electronically signed” 		Contact information: Phone -
Pager -
email -
Stamp Wet Electronic
Please fax this referral to the number below. Community Respiratory Services
Phone: 604-514-6106 Toll-free Phone: 1-888-514-6106 Fax: Click to copy www.fraserhealth.ca/your_care/community_respiratory_services
Subject:
Created May 19th 2023 by Dr. John Robertson, licensed under the GNU General Public License, version 2(GPLv2)

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