BREATH TESTING REFERRAL

Patient Details: Affix patient label below Consultation Required:

☐ Helicobacter Breath Testing

Name:       ☐ Hydrogen Breath Testing

DOB:       Lactulose* Date:       ☐ Glucose^ Date:      

Phone:       ☐ Lactose Date:       ☐ Sorbitol Date:      

☐ Fructose Date:       ☐ Sucrose Date:      

* Compulsory control Test ^ For small bowel bacterial growth

Clinical notes and current medications: Diagnostic Breath Testing:      PLEASE NOTE: ALL TESTS START AT 9:00AM and may take up to 3 hours.

Late arrivals may be rescheduled.

All tests must be done on separate days and require fasting, therefore diabetics should consult their doctor for diabetes management before and during testing. See below for important patient information and pre-test preparation instructions.

All tests require a non-refundable, out-of-pocket payment on the day by EFTPOS, VISA or Mastercard. There is NO Medicare rebate for Hydrogen Breath Testing. There is a Medicare rebate for HP Breath Testing.

Home Helicobacter Breath Test Kits are available from MVSC, please email:reception@mvscentre.com.au for details.

Please provide this referral to Moonee Valley Specialist Centre to arrange an appointment. Direct appointment requests can be made online at: mvscentre.com.au/appointment

Referring Doctor Details:Name:      

Provider No:      

Doctor Stamp/Signature