{"id":583,"date":"2024-01-24T09:15:01","date_gmt":"2024-01-24T15:15:01","guid":{"rendered":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/?page_id=583"},"modified":"2024-01-24T09:15:01","modified_gmt":"2024-01-24T15:15:01","slug":"fmp-esophageal-function-lab-referral-form","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/fmp-esophageal-function-lab-referral-form\/","title":{"rendered":"FMP Esophageal Function Lab Referral Form"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_154' style='display:none'><div id='gf_154' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_154' id='gform_154'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/583#gf_154' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_154' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_154_1\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >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.<\/br><\/br>\n<strong>Required Information<\/strong><\/br>\n<ul>\n<li>Patient demographics page from your data system<\/li>\n<li>H&P and\/or clinic notes from past 12 months<\/li>\n<li>Copy of front and back of all insurance cards <\/li>\n<li>Most recent endoscopy results<\/li>\n<li>Barium swallow results<\/li>\n<li>Radiology reports and images<\/li>\n<\/ul>\n***Of note, some insurances do not reimburse for pH\/Impendance testing. In these scenarios, dual sensor pH testing may be substituted.***<\/div><fieldset id=\"field_154_2\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Patient Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_154_2'>\n                            \n                            <span id='input_154_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_154_2_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_154_2_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_154_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_154_2_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_154_2_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_154_17\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_154_17' >Patient Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_154_17' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_154_3\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_154_3' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_154_3' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_154_3_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_154_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_154_3' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_154_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Office contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_154_5'>\n                            \n                            <span id='input_154_5_3_container' class='name_first' >\n                                                    <input type='text' name='input_5.3' id='input_154_5_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_154_5_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_154_5_6_container' class='name_last' >\n                                                    <input type='text' name='input_5.6' id='input_154_5_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_154_5_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_154_6\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Referring MD Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_154_6'>\n                            \n                            <span id='input_154_6_3_container' class='name_first' >\n                                                    <input type='text' name='input_6.3' id='input_154_6_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_154_6_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_154_6_6_container' class='name_last' >\n                                                    <input type='text' name='input_6.6' id='input_154_6_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_154_6_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_154_7\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_154_7' >Referring MD NPI (for first referral)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_7' id='input_154_7' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_154_8\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Referring MD Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_154_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_154_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_154_8_1' value=''    aria-required='true'    \/>\n                                        <label for='input_154_8_1' id='input_154_8_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_154_8_2_container' >\n                                        <input type='text' name='input_8.2' id='input_154_8_2' value=''     aria-required='false'   \/>\n                                        <label for='input_154_8_2' id='input_154_8_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_154_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_154_8_3' value=''    aria-required='true'    \/>\n                                    <label for='input_154_8_3' id='input_154_8_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_154_8_4_container' >\n                                        <select name='input_8.4' id='input_154_8_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_154_8_4' id='input_154_8_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_154_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_154_8_5' value=''    aria-required='true'    \/>\n                                    <label for='input_154_8_5' id='input_154_8_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_154_8_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_154_9\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_154_9' >Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_154_9' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_154_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_154_10' >Fax<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_154_10' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_154_11\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Indications\/Clinical concern<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_154_11'><div class='gchoice gchoice_154_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Suspected esophageal motility disorder'  id='choice_154_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_11_1' id='label_154_11_1'>Suspected esophageal motility disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_154_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='Pre-fundoplication evaluation\/studies'  id='choice_154_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_11_2' id='label_154_11_2'>Pre-fundoplication evaluation\/studies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_154_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='GERD'  id='choice_154_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_11_3' id='label_154_11_3'>GERD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_154_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='Atypical GERD symptoms'  id='choice_154_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_11_4' id='label_154_11_4'>Atypical GERD symptoms<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_154_11_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.5' type='checkbox'  value='Dysphagia, NOS'  id='choice_154_11_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_11_5' id='label_154_11_5'>Dysphagia, NOS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_154_11_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.6' type='checkbox'  value='Failed esophageal manometry'  id='choice_154_11_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_11_6' id='label_154_11_6'>Failed esophageal manometry<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_154_11_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.7' type='checkbox'  value='Other'  id='choice_154_11_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_11_7' id='label_154_11_7'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_154_12\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_154_12' >If other --please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_154_12' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_154_13\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Please check test needed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_154_13'><div class='gchoice gchoice_154_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='High Resolution Esophageal Manometry Testing'  id='choice_154_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_13_1' id='label_154_13_1'>High Resolution Esophageal Manometry Testing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_154_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='24 hr pH\/Impedance Testing + Esophageal Manometry'  id='choice_154_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_13_2' id='label_154_13_2'>24 hr pH\/Impedance Testing + Esophageal Manometry<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_154_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Bravo Reflux Monitoring'  id='choice_154_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_13_3' id='label_154_13_3'>Bravo Reflux Monitoring<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_154_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='EndoFLIP'  id='choice_154_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_13_4' id='label_154_13_4'>EndoFLIP<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_154_16\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Please check test needed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_154_16'><div class='gchoice gchoice_154_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='On acid suppressive therapy'  id='choice_154_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_16_1' id='label_154_16_1'>On acid suppressive therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_154_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Off acid suppressive therapy'  id='choice_154_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_154_16_2' id='label_154_16_2'>Off acid suppressive therapy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_154_15\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_154_15' >Please upload medical records here<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_15' id='input_154_15' type='file' class='large' aria-describedby=\"gfield_upload_rules_154_15\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_154_15'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_154_15'><\/div><\/div><\/div><div id=\"field_154_14\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><strong>Jacalyn Witherspoon<\/br>\n<address>1808 7th Avenue South, BDB 354<\/br>\nBirmingham, AL  35233<\/address>\n(205) 975-3217 -  Fax (205) 975-6201<\/strong>\n<\/br><\/br>\n<i>Patient will receive a letter with details about their appointment(s), maps, and informational brochures. 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