RefluxUK Physiology Referral Form
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Email
*
example@example.com
Patient Phone Number
*
Type of Test
HRM
24 hour impedance
Bravo
SIBO
Is the patient insured?
*
Yes
No
Which insurer is the patient covered by?
Insurance Policy Number
Does the patient require rumination protocol?
*
Yes
No
Does the patient have any known allergies?
*
Yes
No
Unknown
Please add known allergies below:
Is the patient able to have local anaesthetic (e.g. lignocaine throat spray) if required?
*
Yes
No
Preferred location(s)
*
London
Tunbridge Wells
Birmingham
Manchester
No preference
Reflux-related medical history (or attach clinic letter below)
Attach Clinic Letter
Browse Files
Drag and drop files here
Choose a file
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of
Referring Clinician Name
*
First Name
Last Name
Referring Clinician Email
*
example@example.com
Referring Clinician Signature
*
Continue
Continue
Should be Empty: