FMP Esophageal Function Lab Referral Form

Thank you for your interest in UAB. Your completion of all the fields below and attachment of medical records will ensure that there are no unnecessary delays in the evaluation of your patient.

Required Information

Patient demographics page from your data system
H&P and/or clinic notes from past 12 months
Copy of front and back of all insurance cards
Most recent endoscopy results
Barium swallow results
Radiology reports and images

***Of note, some insurances do not reimburse for pH/Impendance testing. In these scenarios, dual sensor pH testing may be substituted.***

Patient Full Name(Required)

First Last

Patient Phone Number(Required)

Date of Birth(Required)

Office contact(Required)

First Last

Referring MD Name(Required)

First Last

Referring MD NPI (for first referral)(Required)

Referring MD Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Fax(Required)

Indications/Clinical concern(Required)

Suspected esophageal motility disorder

Pre-fundoplication evaluation/studies

GERD

Atypical GERD symptoms

Dysphagia, NOS

Failed esophageal manometry

Other

If other --please explain(Required)

Please check test needed(Required)

High Resolution Esophageal Manometry Testing

24 hr pH/Impedance Testing + Esophageal Manometry

Bravo Reflux Monitoring

EndoFLIP

Please check test needed(Required)

On acid suppressive therapy

Off acid suppressive therapy

Please upload medical records here

Max. file size: 8 MB.

Jacalyn Witherspoon

1808 7th Avenue South, BDB 354
Birmingham, AL 35233
(205) 975-3217 - Fax (205) 975-6201

Patient will receive a letter with details about their appointment(s), maps, and informational brochures. Please notify us of changes in patient’s condition or contact information.