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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
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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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