RefluxUK Physiology Referral Form
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Day
-
Month
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Email
*
example@example.com
Patient Phone Number
*
Is the patient insured?
*
Yes
No
Which insurer is the patient covered by?
Insurance Policy Number
Test(s) required - multiple choice
*
High-Resolution Oesophageal Manometry
24-hour pH/Impedance Monitoring
Hydrogen/Methane SIBO Breath Test
High Resolution Anorectal Manometry - Manchester only
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
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Referring Clinician Name
*
First Name
Last Name
Referring Clinician Email
*
example@example.com
Referring Clinician Signature
*
Continue
Continue
Should be Empty: