UF Health GI / Endoscopy 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 cancer 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) Colonoscopy date: __________________________________ h Gastrointestinal bleeding / iron deficiency with h Personal history of colorectal cancer suspected upper GI source Last colonoscopy date: ______________________________ h Barrett’s esophagus 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 / LIVER RELATED Relation: ________________________ Age at dx: ________ h Paracentesis* h Fecal occult blood positive h Liver biopsy* 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 Enteroscopy*: 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.