Patient Name: __________________________________

Date of Birth: __________________________________

Health Card #: _________________________________

CAR DI O-R ESP I RATOR Y SERVI CES Home Phone #: _________________________________

Alternate Phone #: ______________________________
OUT-P ATI ENT R EQUI SI TI ON
Guelph General Hospital Ordering Physician: ______________________________
115 Delhi St. Guelph, Ont, N1E 4J4 Copies to: _________________________________

Appointment Date: ___________________ Appointment Time: ___________________

Arrive in Ambulatory Care (1st Floor) 15 minutes before your test to be registered.
• Bring this requisition with you to your appointment. We are not able to do your test without this requisition.
• No Perfumes, Colognes, or other fragrances please.
• Bring a list of your current medications with you.
• Do Not Smoke the day of the test. No alcohol or caffeine (coffee, tea, cola), for 4 hours before the test.
• If possible, Do Not Use puffer/Inhaler medication for 6 hours before the test. Take all your other medication
as you normally do.
• Note that metre parking is 1 hour maximum and will not be adequate for most tests.

Please check Test(s) Required:

 Pulmonary Function Test (PFT) (Includes FVL Pre and Post Bronchodilator, Lung Volumes, DLCO)
 Spirometry (Includes FVL Pre and Post Bronchodilator)
 Methacholine Challenge Test (MCT)Pre and post spirometry is mandatory prior to a MCT. Please send spirometry
results to GGH CRS. Preapproval by GGH Respirologist is required for MCT. A Methacholine Challenge Test is a special blowing
test which will help show how sensitive your airways are (i.e Asthma). You will be asked to inhale different doses of the
medication Methacholine. Follow the instructions as listed above – PLUS:
 DO NOT TAKE - Ventolin or Airomir (salbutamol), or Bricanyl (terbutaline) for 8 hours before the test.
 DO NOT TAKE – Atrovent (ipratropium), Combivent, or Singulair (montelukast), for 24 hours before the test.
 DO NOT TAKE – Theophylline, Advair, Spiriva (tiotropium), Serevent (salmeterol), Oxeze (formoterol), Seebri
(glycopyrronium), Tudorza Genuair (aclidinium) Onbrez (indacaterol),Incruse, Duaklir, Zenhale, Inspiolto, Ultibro, Anaro,
Breo, or Symbicort for 48 hours before the test.
 DO NOT TAKE – Reactine (cetirizine)or Zyrtec for 3 days before the test.
 Take all of your other medications as you normally do, unless you are told otherwise by your physician.
NOTE: If shortness of breath bothers you when you stop taking your medication, start taking them as you normally do
 Arterial Blood Gases (ABG’s) –  On room air? OR  On O2 (specify FiO2) __________
 Home Oxygen Assessment – includes ABG’s and Exercise oximetry, with and without oxygen, as required.
• If you have oxygen, be sure to bring it with you.
 Home Oxygen Titration Study – includes walking oximetry on room air and O2. No ABG’s
• If you have oxygen, be sure to bring it with you.

Reason for test / Clinical Information / Special Considerations: ____________________________________

Physician Signature: ______________________________ Date: _______________________________

Cardio-Respiratory Services Phone 519-837-6416 Fax – 519-837-6439