Refer Now Please enable JavaScript in your browser to complete this form.Patient Name *Date of Birth *Patient Contact Number *Patient Email *We provide comprehensive swallowing evaluation with the following diagnostic services: (please tick)Flexible Endoscopic Evaluation of Swallowing (FEES)Videofluoroscopy Swallow Study (VFSS) Download Radiology Referral Form HereLaryngopharyngeal Reflux (LPR) Testing - Oral Salivary Pepsin Mailout Kit (Peptest(R))Laryngopharyngeal Reflux (LPR) Testing - 24 hour dual probe pH/Impedance MonitoringTransnasal Oesophagoscopy (TNO)High Resolution Pharyngeal ManometryHigh Resolution Oesophageal ManometryConsultation with Swallow Assessment Team: ENT and Speech Pathologist (Includes Flexible Endoscopic Swallowing Evaluation)Biofeedback Swallowing TherapyDr Paul Paddle ENT Surgeon / Laryngologist Ms Claire Stanley Speech Pathologist Dr Anthony Rotman ENT Surgeon / Laryngologist Dr Christopher Schneider Functional Gastro-enterologist Level 1, 449 Swan St Richmond VIC AUSTRALIA 3121 Phone: +1300-952-808 admin@melbswallow.com.au Referral Details (include reason for referral) *Relevant Medical History *Current Medications (may prefer to attach list)Priority for appointment: *RoutineUrgent Name and contact details of referring agentReferrer NameProvider Number *Referrer Contact Number *Clinic Name and AddressFile Upload Click or drag files to this area to upload. You can upload up to 3 files. Upload any additional test results, medication lists or relevant information hereSignature *Clear SignaturePhoneSubmit Download PDF
01.01.2024 Up your Dysphagia Game with MSAC Academy in 2024! Happy New Year! Is one of your New Year’s resolutions to increase your knowledge... More Info