Referral form to Kootenai Clinic Gastroenterology & Endoscopy 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name and Date of Birth in the designated fields. Ensure accuracy for proper identification.
3. Input the Patient Phone Number(s) for contact purposes. This is crucial for follow-up communications.
4. Fill in the Referring Provider's name and phone number. This information helps streamline communication between providers.
5. Select one option from the 'Referring for' section, indicating whether it's an office consult or a specific procedure like Colonoscopy or EGD.
6. Detail any Medical Condition(s) present by checking relevant boxes and providing additional information where necessary, such as the date of the last EKG.
7. List any Medications, including diabetic medications and anti-coagulation details, ensuring you follow any specific protocols mentioned.
8. Finally, review all sections for completeness before faxing this form along with any required documents to (208) 625-4596.

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