UF Health GI / Scheduling phone: 352.265.3636 GI Procedure Order (External Provider) Scheduling fax: 352.627.4074

Please complete patient information below, or attach patient demographic information prior to fasting.

Patient’s Name – Last: ______First: ______MI: ______DOB: ______/______/______Home #: ______Work #: ______Cell #: ______Referring Provider (Print Name): ______Office Phone #: ______

Priority Level: h STAT (Within 5 days) h Urgent (1-2 weeks) h Routine

COLONOSCOPY PATIENT SAFETY h Screening: 50 years or older average age risk For patient safety reasons, please include the following • No personal/family history of polyps or information on your patient: • Should be 10 years from last colo, or 4 years from last flex h List of medications sig unless mitigating factors per Medicare guidelines h Surgical and medical history h Diagnostic (state indication below) EGD (UPPER ENDOSCOPY) SPECIFIC INDICATIONS h Upper abdominal distress/dyspepsia h Personal history of polyps h 50 year old h Failure after test/treatment Type: ______h Dysphagia / Odynophagia (circle one) date: ______h Gastrointestinal bleeding / deficiency with h Personal history of suspected upper GI source Last colonoscopy date: ______h Barrett’s surveillance h Personal history of inflammatory bowel disease Date of last EGD: ______h Colon cancer surveillance h Diagnosis h Other, please be specific: ______h Family history of colorectal cancer or polyps Relation: ______Age at dx: ______HEPATOLOGY / RELATED Relation: ______Age at dx: ______h * h Fecal occult positive h Liver * h Iron deficiency: If colonoscopy does not reveal bleeding source *Request will be reviewed by Hepatology Attending (melena or IDA), do you want an EGD done at the same time? h Yes h No ADVANCED PROCEDURE h Hematochezia (rectal bleeding) (To be reviewed by an Advanced Endoscopist prior to scheduling) h Evaluation of abnormality on barium enema or other pertinent EUS*: Upper EUS h Rectal EUS h test, describe: ______h ERCP* h ERCP with Cholangioscopy* (SpyGlass) ______h Per-oral endoscopic myotomy (POEM)* ______h Endoscopic submucosal dissection (ESD)* h Other, describe: ______h Small bowel *: Push h (does not require review) ______Spirus antegrade h Spirus retrograde h ______h Capsule* h Capsule with EGD placement* ______*Please include all notes pertaining to diagnosis along h The referring physician approves the appropriate bowel cleansing with radiology reports and disks. solution and preparation per GI protocol if required for procedure h Indication: ______

Ordering physician’s signature (required) MD# Date Time

Patient Name: Patient Identification #: *RX0001* RX0001

Revised 4/19/17 GI Procedure Order (External Provider) PS120633