The Nelson Health Centre Direct Access Diagnostic Flexible Sigmoidoscopy Referral Form

The Nelson Health Centre Direct Access Diagnostic Flexible Sigmoidoscopy Referral Form If this form does not contain all the required information, it will be returned. Fax no. 020 8725 4215 Email [email protected]

PATIENT DETAILS Date Requested

Surname GP

First Name Pts Address

DOB Pts Tel. No. ROUTINE / URGENT (please circle)

CLINICAL DETAILS INDICATIONS  Duration / Details

Bright red, fresh rectal bleeding:

In the absence of diarrhoea, change of bowel habit, weight loss, abdominal pain, iron deficiency anaemia or significant family history

Rectal Mass: Details:

Peri-anal pain: Details:

IMPORTANT INFORMATION Is the patient on Warfarin or Clopidogrel or any similar agent (e.g. Dagibactran)? If yes please state which: (Note that these do not need to be stopped for diagnostic flexible sigmoidoscopy).

EXAMINATION

ABDO: PR findings:

Requested by ………………………… Signature ……..……………………

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