Autonomic Function Testing Referral

Tel: 02 9388 0615 | Email: [email protected]

Patient Details

Patient Name*

Date of Birth

Mobile Number*

* Required — we contact the patient directly to arrange the appointment.

Test Required

Full Autonomic Function Testing
Including Valsalva manoeuvre, Heart Rate Variability (deep breathing), sustained handgrip, active standing test, and SudoScan for sudomotor function assessment

SudoScan Only
For patients who have already had cardiovascular parameters tested

Hypermobility Assessment
Structured clinical assessment for joint hypermobility and associated connective-tissue features, with written report

Referral Type

Self-referral — no referral letter
I understand a doctor's referral is not required for these tests, and that the tests themselves are not covered by a Medicare rebate.

Referring Doctor — OR — Doctor to Receive Copy of Report

Self-referring patients: enter your GP or specialist here if you would like them sent a copy of the report.

Doctor Name*

Provider Number

Doctor Email

I am the referring practitioner (or am submitting on their behalf with their authority), and I have the patient's consent to provide these details.

The information you provide is used only to arrange and report on this test. See our privacy policy.

Suite 301 Harley Place, 251 Oxford St, Bondi Junction NSW 2022

Testing takes 40–60 minutes. No referral required. The tests are not Medicare rebated.