JOSEPH'S SCREENING COLONOSCOPY REFERRAL FORM 2026

1. Click ‘Get Form’ to open JOSEPH'S SCREENING COLONOSCOPY REFERRAL FORM in our editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, health insurance number (HIN), date of birth, street address, city/town, postal code, home phone number, and work phone number.
3. In the 'Indication for Procedure' section, check all applicable boxes that apply to the patient's condition, such as positive FOBT or a first-degree relative with colorectal cancer.
4. Complete the 'Referring Physician Information and Instructions' section by entering the physician's name, referring physician number, office phone, and fax number.
5. Fill out the 'Clinical Information' section. Indicate any allergies and conditions that may affect the procedure by checking relevant boxes. Include medications with doses and frequency if applicable.
6. Finally, ensure you review both risks and benefits of colonoscopy with the patient. If you do not wish for direct referral for follow-up of positive findings, check that option before signing and dating the form.

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