Phone/Fax:  Charlottetown  626-3376     Kensington  836-3376     Toll Free:  1-866-886-3376

1125 Rustico Road, Charlottetown, PE  C1E 0X6

Physician Referral Form

Patient Information:

     Name: ____________________________________________     Phone: __________________

     Address: ____________________________________________________________________

     Postal Code: ______________________     PHN __________________________

Referring Physician:

     Name:________________________________________________     Phone: _____________________

     Address: _____________________________________________________________________________

Oxygen Therapy:

     _____ Home O2 at _____lpm _____continuous _____PRN

     _____ Portable O2 at _____lpm _____PRN

     _____ Maintain SpO2 > _____%

     _____ Assess for O2 Therapy

Sleep Therapy:

     _____ Overnight oximetry screening on room air OR on O2 at _____lmp

     _____ Repeat overnight oximetry

     _____ Alice NIght One (Level 3) on room air

     _____ Auto-CPAP for OSA

     _____CPAP at _____cmH2O

     _____ Auto BiPAP OR _____BiPAP (Insp _____cmH2O/Exp _____cmH2O)

Other (e.g. aerosol, PEP, Acapella, etc.):

     ___________________________________________________________________________

     ___________________________________________________________________________

Physician Signature: ______________________________________  Date: _____________