UPPER & LOWER GI ENDOSCOPY REFERRAL FORM

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 doctor	
Forename	Forename	GMC/HPC/NMC No	     	
Surname	Surname	Address	Registered GP address	
Address

	Patient address house
Patient address road
Patient address locality
Patient address post town
			
Date of Birth	Date of birth	Referring CCG Code	Registered GP PCT	
Telephone (Home)	Patient preferred telephone	Referring Practice Code	Registered GP practice ID	
Telephone (Work)	     	Telephone No.         
(for urgent clinical findings)	Registered GP phone number	
Telephone (Mobile)	Patient mobile telephone number	Fax No.	Registered GP fax number	
E-mail Address	     	NHS.net mail only	     
	
Gender	Ethnicity	Wheelchair user?                             Yes 	
Physical/Communication difficulties (specify if any):
     	The patient must be ambulant, or if a wheelchair user they must be able to transfer independently onto the examination couch and be able to change position during the procedure	
If interpreter required, language:
     	Does the patient have the capacity to give informed consent to the procedure.   Yes            No     	
		
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 taken after pre-assessment		Date of referral ______________	
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 LV:  July 2015