Richmond CCG

LOWER GI ENDOSCOPY REFERRAL FORM

Please note – we are unable to accept referrals for patients under 18 years of age

PATIENT	REFERRER
NHS Number	~[NHS Number]	Name	~[Free Text:Referring GP Fullname]
Forename	~[Forename]	GMC/HPC/NMC No
Surname	~[Surname]	Address	~[Surgery Address Line 1]

~[Surgery Address Line 2]

~[Surgery Address Line 3]

~[Surgery Address Line 4]

~[Surgery Address Line 5]
Address	~[Patient Address Block]

~[Post Code]
Date of Birth	~[Date Of Birth]	Referring PCT Code
Telephone (Home)	~[Telephone Number]	Referring Practice Code
Telephone (Work)	Telephone No.

(for urgent clinical findings)	~[Surgery Tel No.]
Telephone (Mobile)	~[Mobile Phone Number]	Fax No.
E-mail Address	NHS.net mail only
Gender	~[Sex]	Eligible for and does require NHS funded transport?

(car transport only) Yes
Physical/Communication difficulties (specify if any):

Wheelchair user? Yes
If interpreter required, language:	The patient must be ambulant, or if a wheelchair user they must be able to transfer independently onto the examination couch.
Ethnicity: ~[Ethnicity]
PRESENTING COMPLAINT & PROVISIONAL DIAGNOSIS

Please provide as much relevant clinical information as possible to ensure the most appropriate investigation is performed.

PR Bleeding
Urgency
Other:
Tenesmus
Constipation
Routine follow up
Altered bowel habit
Diarrhoea
Pain/Discomfort
Please indicate which test you require:

(we do not offer Gastroscopy)
Flexible Sigmoidoscopy
Colonoscopy
Decision taken after pre-assessment
Date of referral ~[Today...]
Procedures related to the presenting symptoms and clinical findings may be performed/undertaken subject to informed consent.
The patient will receive bowel preparation (picolax, picolax and senna, klean-prep or moviprep).

I can confirm that this patient is fit to receive bowel preparation medication: (the patient cannot be booked unless this box is ticked) Yes
Is there any possibility of the patient being pregnant?	Yes No

Date of last period / /
Relevant Past Medical History (include previous & current treatment/medication where relevant)

Family history of Bowel Cancer	Details:
History of problems with sedation/anaesthesia	Details:
Previous colonoscopy or sigmoidoscopy	Details:
Previous abdominal surgery	Details:
Diabetes	Medication:
Anti-coagulation therapy	Medication:
Hepatitis C	Details:
Heart murmur or valve replacement	Details:
Allergies	Details:

Please fax or e-mail this form to the InHealth Patient Referral Centre:

Fax: 0333 200 1163 E-mail: inl.inhealthreferrals@nhs.net

Tel: 0333 202 0297

www.inhealthgroup.com

EMIS PCS July 2015

INHEALTH

Caroline Meechan

2015-07-23

InHealth Ltd