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: <<Patient Demographics:Full Name>>
ADDRESS: <<Patient Demographics:Full Address>>
DOB: <<Patient Demographics:DOB>>		  SEX:<<Patient Demographics:Sex>>
TELEPHONE: (H) <<Patient Demographics:Phone (Home)>> , (M) <<Patient Demographics:Phone (Mobile)>>  EMAIL:<<Patient Demographics:E-mail>>
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:					
…………………………………………				
…………………………………………	

Referring doctor's name, address, fax, email  & provider number:					Referring Doctor: <<Doctor:Name>>
Address: <<Doctor:Full Address>>
Fax: <<Doctor:Fax>>
Provider No: <<Doctor:Provider Number>>

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

Fax this request to: (02) 9113 3993