Hospital Referrals | RTS

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Tel: 08 9331 6371

Fax: 08 9337 2284

HOSPITAL CLINICAL LUNG FUNCTION REFERRAL FORM 2025

Request Date*

Hospital Name*

Hospital Name (other)

if other please state

Hospital Department*

Requesting Doctor / Consultant*

Provider No

Patient Full Name*

Patient DOB*

Day

Month

Year

Patient Phone / Mobile*

Patient Address*

Patient Medicare Number*

Gender

Female

Male

Undisclosed

Urgent Results

Recent HB (<3 months)

Clinical Tests*

Full Lung Function (PFT)

Full Lung Function With Inspiratory Loop

Fraction Of Expired Nitric Oxide Analysis (FENO)

Spirometry

Bronchial Provocation (MANNITOL)

6 Minute Walk Test (6MWT)

Respiratory Muscle Strength

Altitude Simulation

Pre-existing Conditions*

Asthma

COPD

Interstitial lung disease

Bronchiectasis

Cystic fibrosis

Pulmonary hypertension

Asbestosis

Silicosis

None

Clinical Notes

File upload

Results Email*

Call

(08) 9331 6371

Email

info@respiratorytesting.com.au

Follow

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