Get the free Gastroenterology Motility Laboratory Referral Form - dhmc

Phone: (603) 650-5215 Fax: (603) 650-5225 Gastroenterology Motility Laboratory Referral Form Referring Provider: Patient Name: Office Phone: DOB: Office Fax: DMC MR#: Address: Address: Please note:

How to fill out gastroenterology motility laboratory referral

How to fill out a gastroenterology motility laboratory referral:

1. Begin by entering the patient's personal information, including their full name, date of birth, and contact information. Make sure all the details provided are accurate and up-to-date.
2. Include the referring physician's contact information, including their name, specialty, and clinic or hospital affiliation.
3. Indicate the reason for the referral and provide a brief medical history of the patient, including relevant symptoms, previous diagnoses, and any treatments or medications currently being taken.
4. Specify the type of motility study or test the patient requires, such as esophageal manometry, anorectal manometry, or gastric emptying study.
5. If any specific preparation or dietary restrictions are necessary for the test, clearly state them in the referral form. For example, a patient undergoing a gastric emptying study may need to fast for a certain number of hours prior to the test.
6. Provide any additional relevant information that may assist the motility laboratory in conducting the study, such as any known allergies, medical conditions, or disabilities the patient may have.
7. Finally, ensure that the referral is signed and dated by the referring physician.

Who needs a gastroenterology motility laboratory referral?

1. Patients experiencing gastrointestinal symptoms such as difficulty swallowing, heartburn, regurgitation, bloating, abdominal pain, constipation, or diarrhea may require a gastroenterology motility laboratory referral.
2. Individuals who have been diagnosed with or suspected to have a motility disorder, such as achalasia, gastroparesis, or irritable bowel syndrome with constipation (IBS-C), may be referred for motility testing to evaluate their digestive system's functionality.
3. Patients who have not responded to initial treatments or medications for their gastrointestinal symptoms may be referred for further evaluation through motility studies.
4. Individuals who have a history of gastrointestinal surgeries or conditions that could impact their digestive system's motility, such as gastric bypass surgery, may require a motility laboratory referral to assess any post-operative complications or ongoing issues.

For pdfFiller’s FAQs

What is gastroenterology motility laboratory referral?

Gastroenterology motility laboratory referral is a request for diagnostic testing to assess the movement and function of the gastrointestinal tract.

Who is required to file gastroenterology motility laboratory referral?

Gastroenterologists, primary care physicians, or other healthcare providers may be required to file gastroenterology motility laboratory referral.

How to fill out gastroenterology motility laboratory referral?

Gastroenterology motility laboratory referral can be filled out by providing relevant patient information, indication for referral, and any other pertinent details.

What is the purpose of gastroenterology motility laboratory referral?

The purpose of gastroenterology motility laboratory referral is to investigate and diagnose conditions related to the movement and function of the gastrointestinal tract.

What information must be reported on gastroenterology motility laboratory referral?

Information such as patient demographics, medical history, symptoms, and any relevant test results must be reported on gastroenterology motility laboratory referral.

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