Adult Respiratory Care and Rehabilitation Team (ARCaRe)
Referral for Spirometry
Clinic Address:
Royal London Hospital
Lung Function Unit
2nd Floor - Lift Core 8
Whitechapel E1 1BB
Kiran - 0208 223 8509
Mon - Fri between 9.00am and 5.00pm
To Patient: Please ring the number above to book an appointment
To GP/Nurse: Please complete this form fully and hand to patient.
Patient Details: To be completed by GP / Nurse
First Name:
Surname:
DOB:
Address:
Telephone Number:
NHS Number:
Smoking History:
Non-Smoker 
Smoker 
Indication for Spirometry:
Initial Diagnosis 
Ex-Smoker 
Review 
Reason for Referral:
Known Allergies:
Known Infection Risks:
Inhaled Medication: (please attach current prescription from electronic system)
Referrer Details:
(PLEASE SIGN AND PRINT NAME OR PATIENT WILL NOT BE SEEN)
Practice Stamp:
Name:
Signed:
Date:
ARCaRe /Spirometry Referral Form August 2015
Important Information for Patients
In order to make the most of your appointment please ensure the
following:
1. Bring your inhalers and spacer devices with you
2. Do not use your blue inhaler at least 4-6 hours before arrival
3. Please ring to change your appointment if you have had the
following:
a. Antibiotics for your breathing in the last month.
b. Recent surgery or cataracts removed in the past 6 weeks
c. If you are feeling unwell or coughing up blood
What is Spirometry:
A spirometry test is to assess how well your lungs and airways work.
When you attend the clinic at Royal London Hospital on the day of your appointment
you will be asked to perform some simple breathing tests.
You will need to blow through a paper tube at different speeds, which will measure how
open your airways are.
You may also be asked to take your blue inhaler after your breathing test, rest for 15
minutes and then perform the breathing test again. This will measure how effective the
inhaler is for your lungs and airways.
The total duration of the test should last between 30 – 45 minutes.
If you fail to attend your booked appointment, you will be discharged from our
list. It will then be your responsibility to request another referral from your GP.
ARCaRe /Spirometry Referral Form August 2015