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 Gastroenterology 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 abdominal pain/dyspepsia Colorectal cancer screening Dysphagia 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 nausea/vomiting Family history of colon cancer Persistent/chronic diarrhea 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, fecal occult blood, iron Indication______deficiency anemia)
Other______