Referral Form

Referral Form

SCHEDULING PHONE: (303) 788-8888
FAX: (303) 790-2567 or (303) 788-6452
Patient Name:
Referring Provider:
DOB:
Cell Phone:
Home Phone:
Patient Email:
***PLEASE ATTACH THE FORM BELOW SO AS NOT TO DELAY SCHEDULING OF PATIENT:

1) PATIENT DEMOGRAPHIC AND INSURANCE SHEET

2) MUST INCLUDE THE FOLLOWING RECORDS:
CARDIAC, PULMONARY, RECENT H&P, OFFICE VISIT, RADIOLOGY, LABS AND PAST GI PROCEDURES
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We will be happy to schedule a Colonoscopy and/or EGD for reasonably healthy patients for the indications below. An office Consultation is strongly recommended for anything outside of these parameters.
EGD:
Known Barrett’s EsophagusGERD or Chronic heartburn (>6 months) to screen for Barrett’s EsophagusDysphagia or known Esophageal stricture for re-dilationOdynophagia
Colonoscopy: (ages up to 75)
Average risk screening: 45 years or olderHigh risk screening: Start at age 40 for family history of colon cancer or adenoma in 1st degree relative< 60 years old OR 2 or more 2nd degree relatives /OR 10 years below the youngest affected relative.Surveillance of previous adenoma or Colon cancerPositive Hemocult (FOBT), FIT Test or CologuardChronic diarrhea or constipation (> 8 weeks in duration)Mild, rectal bleeding (40 years, up to 75 years old)
Office Consultation Requested:
Condition or symptoms:
Briefly summarize reason for consult:
Should be Empty:

EGD: