Refer Your Patient | The Functional Gut Clinic

Healthcare Professional Information

HCP Name *

HCP Email *

Patient Information

Title

First Name *

Last Name *

Email *

Phone *

Date of birth *

Street Address

City

Postal code

Payment Method *

Insurance Provider

Letter of Guarantee (LOG)

Please provide the Letter of Guarantee (LOG)

Membership Number (insurance)

Pre-Auth Code (insurance)

Patient's Health Status and History

HCP Clinical indication *

Does the patient currently have or has ever had any of the following? (CHECK ALL THAT APPLIES)

Diabetes

Gastrointestinal surgery

A history of cardio-respiratory disease

Been prescribed and Anticoagulants or Antiplatelets

Had IFDs: Hep B/C, HIV, CDIF, MRSA, TB

Any allergies

Been informed that they are at increased risk of vCJD for Public Health purposes

Diagnosed with vCJD or a similar illness (either definite, possible or probable)

Symptoms compatible with vCJD

Does the patient require an interpreter? *

Yes

No

Is the patient fit for physiological diagnostic testing? *

Yes

No

Consent initiated? *

Yes

No

Supporting Documents (optional)

Upload up to 3 files

Please upload relevant test results and other supporting documents

Select the Required Tests

Oesophageal and Pharyngeal Physiology testing: *

High-Resolution Oesophageal Manometry-Z

24-Hour Ambulatory Oesophageal pH-Impedance

24-hour Ambulatory LPR pH-Impedance

High Resolution Pharyngeal Manometry-Z

Biofeedback for Rumination/Supragastric Belching

None

Lower Gastrointestinal Physiology Testing: *

High-Resolution Anorectal Manometry

Stool Microbiome Analysis

None

IMPORTANT!

At-home test kits are marked with an asterisk (*).
If any of the required tests must be conducted in the clinic, please select the
“In Clinic” option below.

At Home or In Clinic Testing *

In Clinic

At Home

I’m still unsure what test my patient needs. (Request a call back)

HCP Phone *

Patient Referral Form