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|[pic] |BREATH TESTING REFERRAL |

|Patient Details: |Affix patient label below | | |Consultation Required: |

| | | |☐ |Helicobacter Breath Testing |

|Name: |    | | | |☐ |

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|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. | |

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| | | |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. | |

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| | | |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. | |

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| | | |Home Helicobacter Breath Test Kits are available from MVSC, please email: | |

| | | |reception@.au for details. | |

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| | | |Please provide this referral to Moonee Valley Specialist Centre to arrange an| |

| | | |appointment. Direct appointment requests can be made online at: | |

| | | |.au/appointment | |

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|Referring Doctor Details: | | | | |

|Name: |      | | | | |

|Provider No: |      | | | | |

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|Doctor Stamp/Signature | | | | |

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