LOWER GI ENDOSCOPY REFERRAL FORM
Barking & Dagenham, Havering and Redbridge
Please note – we are unable to accept referrals for patients under 18 years of age

PATIENT	REFERRER	
NHS Number	NHS Number	Name	Registered GP	
Forename	Forenames	GMC/HPC/NMC No	     	
Surname	Surname	Address	     	
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	If interpreter required, language:      	
Physical/Communication difficulties (specify if any):
     	Wheelchair user?                              Yes 	
	The patient must be ambulant, or if a wheelchair user they must be able to transfer independently onto the examination couch.	
Ethnicity: Ethnic Origin		
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 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  	
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 post, fax or e-mail this form to the InHealth Patient Referral Centre:
Sandbrook House, Sandbrook Way, Rochdale OL11 1RY
Tel: 0333 202 0297 Fax: 0333 200 1163 E-mail: inl.inhealthreferrals@nhs.net
	
www.inhealthgroup.com

Version: EMIS LV Jun 2016