Diagnostic Community Spirometry referral for Lambeth and Southwark

This service provides quality assured diagnostic spirometry where a clinician suspects a possible diagnosis of COPD or asthma. The service does not provide review/ annual spirometry except where the diagnosis is in question or needs to be confirmed.

All patients will be offered reversibility testing with an inhaled bronchodilator as part of this process and therefore clinical authorisation is required with the referral. Without this, spirometry without reversibility will be done. 

Please give clinical authorisation for the administration of 400 mcg Salbutamol or 80mg Ipratropium Bromide below: 

Name of Authorised prescriber: 

Please note that spirometry cannot be performed if the patient has had any of the following in the past 6 weeks
•	Haemoptysis
•	Heart attack or unstable angina
•	Pulmonary embolism
•	Pneumothorax
•	Eye surgery
•	Chest or abdominal surgery
•	Chest, abdominal or cerebral aneurysm

Please use the following template for referral. Please record your contact details below. Thank you 

Date of referral:                                                                           Referrer Name: 
Surgery:                                                                                         Surgery: E-mail:  

Patient Details 
NAME:				AGE				DOB:			SEX:  
NHS Number:			TEL: 				MOBILE: 
ADDRESS:
Ethnicity:							LANGUAGE: 
Add any further information that may help us co-ordinate this persons care e.g. transport needs:

What is the reason for the referral?
Describe the current problem briefly here and attach any previous spirometry results if available