ࡱ> AC@ fbjbjR|R| .$008 HH8(<dz!rMMM  $"%!!M0MMM!HH4!M^H" M jri J!0z!&&&MMMMMMM!!sjMMMz!MMMM&MMMMMMMMM :  Home Oxygen Service (HOS-AR) Referral Form  Thank you for referring your patient to our Home Oxygen Service. The team only accepts patients who have shown pulse-oximetry d" 92% on air or who de-saturate on exercise. Home oxygen therapy should not be prescribed on the basis of breathlessness alone     Date of referral: ( Urgent (within 24 hours Monday to Friday) Date of receipt: ( Routine (within 2 weeks) Main Diagnosis Patient Details Name: NHS No: Address: DOB: Telephone No: Practice Name: GP: Past Medical History include co-morbidities Confirm patients condition is optimally controlled: ( Confirm patients condition is stable for 5 weeks: ( Smoker Yes ( No ( Hospital Consultant (where applicable) Patients referred for LTOT must have been seen by a consultant to confirm diagnosis and optimise treatment Home Oxygen Therapy History Current Oxygen User: Yes ( No ( If YES, what modality: LTOT ( SBOT ( Ambulatory Oxygen ( SpO2 (within the last 7 days): Date: Current Medication (including details of nebuliser therapy): Reason for referral (If emergency oxygen already installed, please attach copy of HOOF A) Referring Clinician Position Contact Details Please email this form to the Home Oxygen Service on  HYPERLINK "mailto:wah-tr.oxygenassessment@nhs.net" wah-tr.oxygenassessment@nhs.net or fax to 01905 775971. We will then directly contact the patient to arrange an appointment/visit. Patients may be seen in clinic or at home. For any enquiries, please phone 01905 681062 <>Z\^`bB n ƼtftO>t0h $CJOJQJ^JaJ h4ayhcCJOJQJ^JaJ,jh4ayh kCJUaJmHnHsH uhCJOJQJ^JaJ h4ayh6CJOJQJ^JaJh;AuCJOJQJ^JaJ h4ayh4ayCJOJQJ^JaJ h6CJ$"jh6CJUmHnHsH uhh5CJ$hhD.5CJ$hh5CJ$hAjh# 4hrB* CJOJQJU^JaJmHnHphtH uZ^`b 8 : ; = > @ A C D E    gdD.$^`a$gdr 6 7 8 9 ; < > ? 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