MANOMETRY REFERRAL

DO NOT COMPLETE THIS FORM IF YOU ARE THE PATIENT - This form is for GPs and other referrers ONLY
Important patient information - please advise patient:

You must confirm your appointment at least two (2) days prior to the date
The facility fee must be paid on the day
$200 (non-pension) – No Medicare Rebate $150 (pension) – No Medicare Rebate
If you need to cancel your appointment, please do so as early as possible.
PLEASE NOTE: Bowel preparation is not required prior to these tests, however a Fleet enema may be administered. Please wear loose clothing.
These are non-invasive procedures using a flexible catheter and a probe. The procedures are not painful but you may feel a bit uncomfortable for a short period of time.

Patient Referral for Endoanal Ultrasound/Anorectal Manometry

* Indicates required field

Which SECR surgeon is this referral for? (select from dropdown menu) *

PATIENT DETAILS

TITLE *

FIRST NAME(s) *

Middle Name (if applicable) *

SURNAME *

Preferred Name (if different to first name) *

Date of Birth DD / MM / YEAR *

Patient's Sex *

Female Male

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Attach any relevant letters, reports, investigations, scans, etc. (MUST BE .PDF FORMAT ONLY) *

Max file size: 20MB

REFERRER DETAILS

Referrer Name *

Provider Number *

Date of Referral *

Your Role (GP/Specialist/Surgeon/Registrar/Intern etc) *

Practice Name or Hospital (if hospital, state department & clinic): *

Address of Practice or Hospital (+ Dept) *

Best Contact Number for Referrer: *

If referring from a hospital, who is patient's usual GP/Practice? *

Reason for Referral

Choose from dropdown menu *

Details of Referral

Please describe patient's symptoms, etc. *

Submit