<p> 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]</p><p>PATIENT DETAILS Date Requested</p><p>Surname GP</p><p>First Name Pts Address </p><p>DOB Pts Tel. No. ROUTINE / URGENT (please circle)</p><p>CLINICAL DETAILS INDICATIONS  Duration / Details</p><p>Bright red, fresh rectal bleeding:</p><p>In the absence of diarrhoea, change of bowel habit, weight loss, abdominal pain, iron deficiency anaemia or significant family history </p><p>Rectal Mass: Details:</p><p>Peri-anal pain: Details:</p><p>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).</p><p>EXAMINATION</p><p>ABDO: PR findings:</p><p>Requested by ………………………… Signature ……..……………………</p><p>Excellence in specialist and community healthcare</p>