Tasmanian Lung Service - Launceston	
6/102 Talbot Rd
South Launceston TAS 7249	PHONE: 03 6331 0580  |   FAX: 03 6331 1351
Healthlink EDI: taslungs
reception@tasmanianlungservice.com
www.tasmanianlungservice.com
Online bookings at www.tasmanianlungservice.com	
Lung Function	Test Request Form	
Patient Details	Referring GP Details	
Name: <<Patient Demographics:Full Name>>
Address: <<Patient Demographics:Full Address>>
DOB: <<Patient Demographics:DOB>>   Sex: <<Patient Demographics:Sex>> 
Medicare No: <<Patient Demographics:Medicare Number>>
DVA No: <<Patient Demographics:DVA Number>>
Phone: (H) <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>	GP Name: <<Doctor:Name>>
Provider No. <<Doctor:Provider Number>>
Practice: <<Practice:Name>>
Address: <<Doctor:Full Address>>
Healthlink EDI: 
Phone: <<Doctor:Phone>>	Referral Date: <<Miscellaneous:Date>>  
Additional report to: <<Send Additional copy of report to:>>
Signature: 
(Considered to be digitally signed if sent via Healthlink)	

Clinical Notes (please insert any notes that are relevant to your referral)	

Tests Required  (Refer to our website for a description of tests available and which ones are appropriate for specific clinical indications)	
	q	Standard Lung Function Test.
 	  (airway function with spirometry or oscillometry, gas exchange (diffusing capacity), lung volumes if indicated)
    q Paediatric Airway Function Test.
              (Oscillometry for children aged 4YO and over)
	q	Airway function, Airway inflammation marker, Gas exchange.
             (airway function with spirometry or oscillometry, exhaled nitric oxide levels and diffusing capacity) 
	q	Respiratory Muscle Strength.
 		(MIPs/MEPs – Maximal inspiratory and expiratory pressures)
	q	Bronchial Challenge Test.
		(airway hypersensitivity test - responsiveness to inhaled mannitol)
     q	Lung Health Clinic in General Practice. - A fully Bulk-billed service for practices that have an arrangement
             with the TLS
            (A selection from spirometry, oscillometry, gas transfer and exhaled NO, as appropriate from clinical notes)	
Referring Doctor Reminder	
Please ask the patient to withhold any breathing medications for 24 hours 
if pre and post airway function measurements are required. 
There are additional requirements for Bronchial challenges and exhaled nitric oxide testing
 – check with our reception at the time of booking.	

					         Directions to our Location
The Tasmanian Lung Service (Launceston) is located in a rendered brick building at 6/102 Talbot Road in South Launceston.
Talbot Road is the main alternative route (rather than using Wellington Street) between the Launceston CBD and Kings Meadows.
Ample parking (including one for wheelchair access) is available at the rear of the property.
Enter by following the path from the carpark to the front of the building.
Online bookings at  www.tasmanianlungservice.com or call 03 6331 0580 to make an appointment
Referrals can be sent securely and directly to us from your clinical software using our HealthLink EDI: taslungs

Template version December 2022
Templates are updated periodically, and the latest version can be found at:
www.primaryhealthtas.com.au/templates/sleep-study-referrals/ 
Download the MD/BP version for your region 	
 
Medication List
<<Clinical Details:Medication List>>