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LHR | London Home Respiratory

Home Oxygen, Aerosol Compressors, CPAP, and Respiratory Devices

519 434 0730oxygen@lhrhealthcare.com106-460 Springbank Dr, London

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About
FAQ’s
Products
Links
Physician Referral
Contact Us

Physician Referral

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Physician Referral

Please fill out the form below or download the Physician Referral Form in PDF Format.

Patient Information

Heath Card Number*

Last Name*

Phone Number*

City*

Date of Birth*

First Name*

Address*

Postal Code*

Treatment

Home Oxygen

Assessment

Set Up

Flow

Flow @

SaO2>92%

With Exertion

Nocturnally

Palliative

Medical Devices

Aerosol Compressor

CPAP

Suction Equipment

Aerochamber/MDI

Services

PFT

Nocturnal Oximetry

Requisitioning Physician/Practitioner

Physician/Practitioner Number

Patient Diagnosis

Asthma

CHF

COPD

Cor Pulmonale

Emphysema

Pulmonary Fibrosis

Comments

Physician Signature

Check this box to authorize physicians signature.

Note: By checking this box, I the physician, am authorizing the prescription in lieu of an actual signature for this electronic form.

Please type the characters*

This helps us prevent spam, thank you.

This field should be left blank

Phone
519 434 0730

Email
oxygen@lhrhealthcare.com

Address
106-460 Springbank Dr. London, ON N6J 0A8

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