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Non-Invasive Pelvic Floor Treatment with EMsella
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Uroflow Test
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Referral for Urodynamics / Uroflow Test
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Referral for Urodynamics / Uroflow Test
Referral for Urodynamics / Uroflow Test
Service Requested
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Urodynamics Test
Uroflow Test
Date of Referral
Referrer's
Name and title (print)
Email
Client Information
Name
Address
Eircode
DOB
Contact No.
Does the client need to be accompanied to the appointment?
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Yes
No
Does the client need an interpreter?
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Client's next of kin
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GP name and address
Contact No.
Reason for referral and presenting symptoms (tick all that apply):
Urinary Urgency
Urge Incontinence
Stress Incontinence
Urinary Frequency
Incomplete bladder emptyin
Slow/Weak urine stream
Hesitancy/difficulty initiating void
Others
Previous Bladder treatment/Investigations
Obstetric History
Medical History
Surgical History
Current Medications
Known allergies
Additional Information
Referring Clinician's signature
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Use your mouse (desktop) or finger/stylus (mobile/tablet) to draw your signature in the area above.
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