Referrals

To refer a patient to one of our programs, complete the on-line referral form below or call:

  • Pulmonary Laboratory: (860) 972-2970

  • Pulmonary Rehabilitation: (860) 972-3637


(* = Required)
* Type of Referral:
Pulmonary Laboratory
Pulmonary Rehabilitation
Pulmonary Lab Requisition:
Test(s) Requested:
Spirometry without bronchodilator
Spirometry before and after bronchodilator
Lung Volumes Measurements
Single-Breath Pulmonary Diffusion Study (DLCO)
Comprehensive Evaluation (spirometry before/after bronchodilator, lung volumes, DLCO)
6 Minute Walk Test
Arterial Blood Gases
Maximal Voluntary Ventilation (MVV)
Maximal Inspiratory Pressure/Maximal Expiratory Pressure (MIP/MEP)
Exercise Study-bronchospasm
Exercise Study-oximeter desaturation without ECG
Provocation/Methacholine Studies
Modified Shunt Study
      Other:
Pre-Op: Yes    No
Scheduled OR Date:  
ICD Code:  
Diagnosis Information:
* Diagnosis:
Patient Information:
* Patient Name:
* Date of Birth:
 Address: Street 1
  Street 2
  City      
  State       Zip
  Country
Work Phone:
Home Phone:
Cell Phone:
Primary Insurance:
  Policy # Group #
Secondary Insurance:
  Policy # Group #
Referring Physician Information:
* Physician Name:
Practice Name:

 Address: Street 1
  Street 2
  City      
  State       Zip
  Country
* Practice Phone:
Practice Fax:
Practice Email Address:
* Preferred Means of Communication: Phone   Fax   Email


Enter code shown above: