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Allergy, Asthma & Immunology Center, P.C.
Vital Prospects Clinical Research Institute, P.C.

Phone: (918) 392-4550

PFT Order Form Form
Please fill out the form below so we know how best to communicate with you. Contact information will NOT be shared or sold to any third parties under any circumstances. * are required.
Please attach recent patient demographics & insurance information to expedite scheduling
* Patient Name
* D.O.B
* Home Phone
Work Phone
Cell Phone
DIAGNOSES
Please provide the diagnoses (signs, symptoms, reason for referral) including codes, and other pertinent clinical information.
* Email
Fax
Mailing Address
PUMONARY FUNCTION TESTING

Complete PFTs + Pre & Post Bronchodilator Testing
Complete PFTs (spirometry, lung volumes and DLCO)
Spirometry (includes flow-volume loop and MVV)
Spirometry + Pre & Post Bronchodilator Testing
Lung Volumes (TLC, FRC, RV, VC, etc.)
Carbon Monoxide Diffusing Capacity (DLCO)
Maximum Inspiratory and Expiratory Pressures (MIP / MEP)

FUNCTIONAL CAPACITY

6 Minute Walk Test (following ATS standards)
Multiple Pulse Oximetry Test
Multiple Pulse Oximetry Test with Oxygen Titration
Cardiopulmonary Exercise Testing

BRONCHIAL HYGIENE & MAINTENANCE

Small Volume Nebulizer Treatment

Albuterol 2.5 mg
Levalbuterol (Circle: 1.25 mg, 0.63 mg)
Levalbuterol (Circle: 1.25 mg, 0.63 mg)

Induced Sputum with hypertonic saline
Nasal Tracheal Suctioning

One on One Patient Education

Deep Breath & Cough
Purse Lip Breathing
MDI and Medication Instruction and Techniques
Asthma education

ADDITIONAL TESTING

Methacholine Challenge Testing (asthma evaluation)
Arterial Blood Gas CIRCLE: room air or supp O2 ___________l/min)

Today     Scheduled

Exercise-induced Bronchospasm
Other

Comments:
Name of Practice/Medical Facility
Date
Referring Physician
Ordering Physician
Date
NPI #
 
* Verification