You are requesting a procedural service which does not constitute the assumption of care and/or consultative services. If these services are requested please refer your patient to and Hepatology.

If no exclusions --FAX THE COMPLETED SHEET, DEMOGRAPIC SHEET,INSURANCE INFORMATION AND RECENT HISTORY AND PHYSICAL TO 559-7777 AND CALL 559-8641 TO SCHEDULE AFTER FORM IS FAXED.

PATIENT NAME MRN CLINIC NAME

REFERRING/ATTENDING PHYSICIAN CLINIC PHONE NUMBER

Please FAX recent History and Physical with most current lab work with this form to (402) 559-7777

**EXCLUSION Criteria: Please refer to **exclusion criteria** section first. If any apply—STOP! Do NOT complete and fax form—Patient MUST BE SEEN IN GI CLINIC- Please Call 559-6040 to schedule this appointment.  Age greater than 80  Coagulopathy (INR greater than 2) Or Bleeding  MI or CVA less than 12 months Disorder  Angina/ Stenting in last 6 months  Platelet count less than 75,000  CHF  Anticoagulation (Coumadin, Heparin, Lovenox,  Artificial heart valves Plavix)  COPD (FEV less than 1.25), Home oxygen use)  Chest Pain within the last 12 months  On 2 or more of the following meds:  Obstructive sleep apnea (Requiring CPAP or Benzodiazepines, Narcotics, Antipsychotics, oxygen) history of sedation complication or intolerance to conscious sedation

 NSAIDs  Aspirin PREFER PATIENT TO HOLD/STOP 5-7 DAYS PRIOR TO PROCEDURE

 Insulin/oral hypoglycemics REFERRING PROVIDER TO ADJUST DOSE AS NECESSARY

Indication(s): Colonoscopy (lower endoscopy) EGD (upper endoscopy)  Persistent /dyspepsia Colorectal cancer screening  or odynophagia  Average risk (no family history, age  Esophageal reflux symptoms that are persistent or greater than 50) recurrent despite appropriate therapy  History of colon polyps  Persistent /  Family history of colon cancer  Persistent/chronic  Post colon cancer resection  GI bleeding (iron deficiency anemia or positive fecal . 1 year post diagnosis, then every 3-5 years occult blood) thereafter if negative  Barrett’s screening  Inflammatory bowel disease  Follow-up gastric ulcer  Persistent/chronic diarrhea Flexible Sigmoidoscopy  Altered bowel habits  Abnormal barium enema/CT colography  GI bleeding (hematochezia, , iron Indication______deficiency anemia)

 Other______