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(905) 773-7843
13291 Yonge Street, Suite 300

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YRPFT Routine Test Request Form

Your Family Doctor can complete the online form for you. Alternatively, you can download the PDF form and bring it to your Family Doctor to complete and send in to us.

Sender's Information
Name*
Email*
Patient Information
First Name*
Last Name*
Address*
Email
Date of Birth*
Home Phone*
Work Phone
Cell Phone*
Age*
Height*
Weight*
Gender*
- Male
- Female
Referring Doctor
Name*
Address*
Phone*
Fax*
Billing #*
Referral Type
Referral for*
- COPD Rehabilitation Program
- PFT only
- PFT with consultation if abnormal results
- Consultation with lung specialist and PFT if indicated
Routine Studies*
- Complete study (includes all routine studies)
- Lung volume measurement and airway resistance tests
- Diffusion capacity
- Spirometry
- Spirometry after bronchodilator
Home Oxygen Assessment*
- Initial assessment with arterial blood gas on room air
- Initial assessment without arterial blood gas (previous ABG done within last 30 days)
- Home oxygen setup (oxygen prescription required for setup)
- Independent exercise assessment (IEA)
Other Tests*
- Non-specific bronchial provocative test (methacholine)
- Arterial blood gas on oxygen
- Arterial blood gas on room air
- 6-minute walking oximetry
- Maximal inspiration and expiration pressures
- Oxygen saturation at rest
Arterial blood gas on oxygen L/min
Reason for test*
Previous pulmonary function test*
History and Physical Information
Present Smoker
- Yes
- No
Stopped X years ago
Did smoke X cigarettes/day for Y years
Hgb Level
Does treatment include: Bronchodilator
- Yes
- No
Does treatment include: Steroids
- Yes
- No
Precautions: Possible TB
- Yes
- No
Precautions: Other infectious disease
- Yes
- No
If yes, please give details
Reason for test*
- Diagnosis
- Surgical follow-up
- Medical follow-up
- Medical-legal
- Pre-surgical assessment
Please state which surgery
Previous pulmonary function test?
- Yes
- No
Medications
Relevant Family/Social/Personal History (if request for PFT study only)
Physical Exam - positive findings
Special Needs
Send reports to:*

Referral Forms

YRPFT Routine Test Request Form

York Region Sleep Disorders Centre
York Region Pulmonary Function Testing Centre
13291 Yonge Street, Suite 300
Richmond Hill, Ontario
Canada L4E 4L6
Phone: (905) 773-7843
Fax: (905) 773-9614
Email: [email protected]

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