UPPER & LOWER GI ENDOSCOPY REFERRAL FORM

Brent - Ealing - Hammersmith & Fulham - Kensington & Chelsea - Westminster

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

DATE OF REFERRAL: EXCLUSIONS: Under age of 18. Weight over 220kg, CKD 5

PATIENT	REFERRER
NHS Number	NHS Number	Name	Registered GP
Forename	Forenames	GMC/HPC/NMC No
Surname	Surname	Address	Practice Address Stacked
Address	Patient Address Stacked
Date of Birth	DOB	Referring CCG Code
Telephone (Home)	Home Telephone	Referring Practice Code
Telephone (Work)	Work Telephone	Telephone No.

(for urgent clinical findings)	Practice Main Telephone
Telephone (Mobile)	Mobile Telephone	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.

Is the patient able to give informed consent to the procedure? Yes No
Ethnicity: Ethnic Origin
LOWER INDICATIONS

UPPER INDICATIONS

Chronic diarrhoea with/without rectal bleeding (please indicate)

Resistant H.pylori infection and/or worsening dyspepsia in spite of appropriate treatment

Rectal Bleeding (please indicate bright red or mixed with stool)

Reflux symptoms unresponsive to lifestyle changes, PPI, H2RA or prokinetic agents

Altered Bowel Habit

Unexplained Weight Loss (please indicate amount and over what period)

Urgency

Dyspepsia

Constipation

Coeliac Disease for diagnostic biopsy

Pain/Discomfort (please indicate if left or right handed)

Dysphagia

Tenesmus

Barretts oesophagus surveillance

Please provide as much relevant clinical information below:

Iron Deficient Anaemia (please provide FBC, Fe, Ferritin, TTg/EMA results). Also consider Colonoscopy

Please indicate which test you require: For BSG guidance see link http://www.bsg.org.uk/clinical-guidance/endoscopy/guidance-on-the-indications-for-diagnostic-upper-gi-endoscopy-flexibible-sigmoidoscopy-and-colonoscopy.html:

Flexible Sigmoidoscopy
Colonoscopy
Decision to be made after pre-assessment (lowers only)
Date of referral System Date
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
Relevant Past Medical History (include previous & current treatment/medication where relevant)
Family history of Bowel or Upper GI Cancer	Details:
Previous Endoscopy	Details:
Previous abdominal surgery	Details:
Diabetes	Medication:
Anti-coagulation therapy	Medication:
Pacemaker (Yes or No - please indicate)	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: Nov 2015

Caroline

2015-11-02