Endoscopy referral form 2026

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

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