Quick Referral for Respiratory and other Services - Search


LINCARE INC. - Fax: 866-261-1208

QUICK REFERRAL FOR RESPIRATORY AND OTHER SERVICES

 

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 Oxygen    LPM     Hrs/Day     SpO2/PaO2    Date of Test: Date Last Seen:  
 Oximetry   Overnight     Spot Check     Titration     Conserver
On Room Air     On CPAP at cmH2O
On O2 at LPM     On Bilevel at IPAP cmH2O
                          EPAP cmH2O
Titration to be performed to achieve O2 saturation of %
 
Care Check (COPD Education and Assessment)  
TEAM   
HeartSteps (CHF Education and Assessment)  
CPAP   cmH2O    Interface        Humidification   Cool   or    Heated  
Bilevel Therapy   IPAP   cmH2O    EPAP   cmH2O    RR        Humidification   Cool   or    Heated
Nebulizer   Stationary   or    Portable
 

PATIENT SELF TESTING PROVIDED BY mdINR

PT/INR  
 

MEDICATION PROVIDED BY RELIANT PHARMACY (PLEASE ATTACH PAD RX)

Ipratropium 0.5mg/Albuterol 2.5mg Unit Dose Solution 3ml     Freq. Qty. Refill
Albuterol Sulfate Unit Dose Solution 0.083% 3ml     Freq. Qty. Refill
Ipratropium Bromide Unit Dose Solution 0.02% 2.5ml     Freq. Qty. Refill
Budesonide INH Suspension 0.25 mg 2ml     Freq. Qty. Refill
Budesonide INH Suspension 0.5 mg 2ml     Freq. Qty. Refill
PERFOROMIST     Freq. Qty. Refill
BROVANA     Freq. Qty. Refill
Special Instructions   
 
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