St George
Hospital

University of
New South Wales

The St George Swallow Centre
Professor Ian Cook MD (Syd) FRACP
Department of Gastroenterology & Hepatology
Level 1, Burt Neilson Wing, St George Hospital
Kogarah, NSW 2217
T:+ 61 2 9113 3111 F: + 61 2 9113 3993
www.stgeorgeswallowcentre.org

REQUEST FOR OESOPHAGEAL FUNCTION STUDIES

PATIENT NAME: <PtName>
ADDRESS: <PtAddress>
DOB: <PtDoB>		  SEX:<PtSex>
TELEPHONE: (H) <PtPhoneH> , (M) <PtPhoneMob>  EMAIL:<PtEmail>
Study Requested: (Ö)

	Oesophageal manometry

	Ambulatory oesophageal pH monitoring
(NB: Cease PPIs or H2RAs at least 7 days prior)

		Other (specify) …………………………………………………………..

Patients routinely bulk billed for these tests

Indication/purpose of this referral:
………………………………………………………………………………………………….
……………………………………………………………………………………,…………….
……………………………………………………………………………………......................
……………………………………………………………………………………......................

Additional report(s) to:					
…………………………………………				
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Referring doctor's name, address, fax, email  & provider number:					Referring Doctor: <DrName>
Address: <DrAddress>
Fax: <DrFax>
Provider No: <DrProviderNo>

Referring doctor signature:……………………….       Date: <Date>

Fax this request to: (02) 9113 3993