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

File Upload

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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.

Known Barrett’s Esophagus GERD or Chronic heartburn (>6 months) to screen for Barrett’s Esophagus Dysphagia or known Esophageal stricture for re-dilation Odynophagia

Average risk screening: 45 years or older High 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 cancer Positive Hemocult (FOBT), FIT Test or Cologuard Chronic diarrhea or constipation (> 8 weeks in duration) Mild, rectal bleeding (40 years, up to 75 years old)

Condition or symptoms:

Briefly summarize reason for consult:

EGD:

Colonoscopy: (ages up to 75)

Office Consultation Requested: