Colonoscopy request form 2025

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The document is a referral form for the New Hampshire Colorectal Cancer Screening Program (NHCRCSP) at Dartmouth-Hitchcock Medical Center. It outlines the necessary information and medical history required for patients being referred for a colonoscopy, including indications for the procedure, personal and family medical history, and medication considerations. The form emphasizes the importance of screening for colorectal cancer in individuals aged 50 and older, as well as other specific medical conditions that may affect the patient's eligibility for the procedure.

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Click ‘Get Form’ to open the colonoscopy referral form in the editor.
Begin by entering the patient's name and date of birth in the designated fields at the top of the form.
Fill in the date of the last visit and provider information, including office number and address.
In the 'Indication for Colonoscopy' section, check appropriate boxes based on patient history, such as screening age or personal/family history of polyps or cancer.
Provide details about any other medical history that may be relevant, including recent treatments or conditions that could affect the procedure.
List any medications being taken by the patient, especially anticoagulants or pain medications, in the medications section.
Finally, ensure that a provider signature and date are included at the bottom of the form before submission.

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2010	4 Satisfied (57 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can I schedule a colonoscopy on my own?

Open Access Colonoscopy makes it easier for patients to take charge of their preventive health. With this option, you can schedule your screening directly no need for an extra appointment with a gastroenterologist. This can save both time and money by eliminating co-pays and additional office visits.

Whats the quickest way to get a colonoscopy?

Benefits of Virtual Colonoscopy Faster, less complicated: VC takes about an hour versus a whole day for standard colonoscopy. Patients can return to work and normal daily activities on the same day and do not need someone to take them home.

Can I self refer for a colonoscopy?

A colonoscopy at our Banbury hospital starts from 1,600. Before the procedure, a consultation with one of our specialists is required for a referral. You can self-refer for a consultation with any of our consultants, with fees starting from 200. This includes a comprehensive assessment beyond just the referral.

How do I request to get a colonoscopy?

To schedule a colonoscopy, your doctor will need to first place a referral for the procedure. You will likely need to make an appointment with your primary care doctor so that he or she can determine if you need a colonoscopy and order the procedure if appropriate.

Can I refer myself for a colonoscopy?

If youre asymptomatic, you can self-refer. If you have cancer symptoms, you must consult your GP for a referral.

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Do you need a referral for a colonoscopy?

Do I need a referral from my family doctor to schedule a colonoscopy? No, you can schedule a colonoscopy without a referral.

Can I schedule myself a colonoscopy?

To determine if youre eligible for Open Access Colonoscopy, a healthcare provider will ask a few questions about your age, family history and personal history of colorectal polyps or cancer. If you qualify, you can schedule your colonoscopy at your convenience no referral needed.

Colonoscopy request form 2025

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How to use or fill out colonoscopy request form with our platform

See more colonoscopy request form versions

Complete this form in 5 minutes or less

Got questions?

Can I schedule a colonoscopy on my own?

Whats the quickest way to get a colonoscopy?

Can I self refer for a colonoscopy?

How do I request to get a colonoscopy?

Can I refer myself for a colonoscopy?

Security and compliance

Complete this form in 5 minutes or less

People also ask

Do you need a referral for a colonoscopy?

Can I schedule myself a colonoscopy?

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