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Endoscopy referral form 2026
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- Click ‘Get Form’ to open the endoscopy referral form in the editor.
- Begin by filling out the 'Patient Information' section. Enter the date, patient's name, UH number, date of birth, and address accurately.
- In the 'Referring MD' section, provide the referring physician's name along with their telephone number, fax number, and email address.
- Indicate the procedure by circling one of the options: Colonoscopy, EGD, EUS/EGD, or EUS/Rectal.
- Specify the indication for the exam by circling either 'Colon cancer screening' or 'Others', and provide details if necessary.
- Complete the 'Pertinent History' section with any relevant medical history that may assist in scheduling.
- Answer all yes/no questions regarding patient consent and medical conditions to expedite scheduling.
- Fill out financial information as required by UTMB Financial Planning Office at the bottom of the form.
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