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)
MM slash DD slash YYYY
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.