BREATH TESTING REFERRAL
Patient Details:
Affix patient label below
Name:
Consultation Required:
☐
Helicobacter Breath Testing
☐
Hydrogen Breath Testing
DOB:
 Lactulose*
Date:
☐ Glucose^
Date:
Phone:
☐ Lactose
Date:
☐ Sorbitol
Date:
☐ Fructose
Date:
☐ Sucrose
Date:
* Compulsory control Test
Clinical notes and current medications:
^ For small bowel bacterial growth
Diagnostic Breath Testing:
PLEASE NOTE: ALL TESTS START AT 9:00AM and may take up to 3 hours.
Late arrivals may be rescheduled.
Referring Doctor Details:
Name:
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.
Provider No:
Home Helicobacter Breath Test Kits are available from MVSC, please email:
reception@mvscentre.com.au for details.
Doctor Stamp/Signature
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