Digestive Richmond Hill: 330 Hwy 7 East, Suite 510 For O ...
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Richmond Hill: 330 Hwy 7 East, Suite 510 Richmond Hill, ON, L4B-3P8 Phone: 905 707-5007, Fax: 905 707 5008 Pickering: 1031 Brock Rd. South Pickering, ON, L1W-3T7 Phone: 905 683 1700, Fax: 905 683 2577 Referral Request Form Patient Information: Name:____________________________________ Date of Birth________________________________ Patient Phone Number:_______________________ OHIP Number:________________________________ Referring Physician___________________________ Physician Fax No:_____________________________ Physician Tel No:_____________________________ Physician Billing No:__________________________ Doctor Information: Book Directly for Procedure? (consultation only) Yes or abdominal pain anemia dark/black stools bloating dysphagia dyspepsia nausea/ vomiting odynophagia reflux symptoms (GERD) weight loss Other (specify) abdominal pain anemia bloating/gas/flatulence blood in stool colon screening (Age 50+) constipation diarrhea history of polyps weight loss family history of colorectal cancer FOBT (+) Follow-up Surveillance Other (specify) Capsule Endoscopy/Colonoscopy Celiac test Urea breath test (H-Pylori test) Lactose intolerance (SIBO Breath Test) Esophageal Manometry (Richmond Hill Only) Liver Scan (Fibroscan) Fecal Calprotectin Three business days cancellation notice required or a $150.00 cancellation fee will apply Lab Services Medical History (please check and list ALL and/or attach a CPP) History of heart disease (please provide recent bloodwork, ECG, & latest cardiology consult) CVA/TIA Any Blood Thinners (indicate which one):_____________ (please provide recent bloodwork). Renal Failure/ Dialysis Patient Diabetes Lung Disease Hepatitis A, B, C (circle one) Medication (Please attach a list if available) Insulin Dependant DM II Allergies ________ ________ ________ ________ ________ Height______ Weight______ Sleep Apnea or on CPAP COPD (please provide CBC, lytes & Creatinine taken within 2 weeks). For Office Use Only Haematology consult (please provide bloodwork) Internal Medicine Consult (please provide bloodwork) Hepatology Consult (please provide blood work) Thoracic Surgical Consult ________ Gastroscopy Colonoscopy Consult Services Reason for Referral? (please check all that apply) No Small Bowel Bacterial Overgrowth Digestive Gastroenterology & Hepatology Health Clinic www.digestivehealth.ca _______________________ _______________________ _______________________ _______________________ _______________________ _______________________
Transcript of Digestive Richmond Hill: 330 Hwy 7 East, Suite 510 For O ...
Richmond Hill: 330 Hwy 7 East, Suite 510Richmond Hill, ON, L4B-3P8 Phone: 905 707-5007, Fax: 905 707 5008
Pickering: 1031 Brock Rd. South Pickering, ON, L1W-3T7 Phone: 905 683 1700, Fax: 905 683 2577
Referral Request Form
Patient Information:Name:____________________________________ Date of Birth________________________________Patient Phone Number:_______________________OHIP Number:________________________________
Referring Physician___________________________Physician Fax No:_____________________________Physician Tel No:_____________________________Physician Billing No:__________________________
Doctor Information:
Book Directly for Procedure?(consultation only)
Yes or
abdominal painanemiadark/black stoolsbloatingdysphagiadyspepsianausea/ vomitingodynophagiare�ux symptoms (GERD)weight lossOther (specify)
abdominal painanemiabloating/gas/�atulenceblood in stoolcolon screening (Age 50+)constipationdiarrheahistory of polypsweight lossfamily history of colorectal cancerFOBT (+)Follow-up SurveillanceOther (specify)
Capsule Endoscopy/ColonoscopyCeliac testUrea breath test (H-Pylori test)Lactose intolerance
(SIBO Breath Test)Esophageal Manometry (Richmond Hill Only)Liver Scan (Fibroscan)Fecal Calprotectin
Three business days cancellation notice required or a $150.00 cancellation fee will apply
Lab Services
Medical History (please check and list ALL and/or attach a CPP)
History of heart disease(please provide recent bloodwork, ECG, & latest cardiology consult)
CVA/TIA
Any Blood Thinners (indicate which one):_____________ (pleaseprovide recent bloodwork).
Renal Failure/ Dialysis Patient
Diabetes
Lung Disease
Hepatitis A, B, C (circle one)
Medication (Please attach a list if available)
Insulin DependantDM II
Allergies
________
________
________
________________
Height______ Weight______
Sleep Apnea or on CPAPCOPD
(please provide CBC, lytes & Creatinine taken within 2 weeks).
For O�ce Use Only
Haematology consult (pleaseprovide bloodwork)Internal Medicine Consult(please provide bloodwork)Hepatology Consult (please provide blood work)Thoracic Surgical Consult
________
Gastroscopy Colonoscopy Consult Services
Reason for Referral? (please check all that apply)
No
Small Bowel Bacterial Overgrowth
DigestiveGastroenterology & HepatologyHealth Clinic
www.digestivehealth.ca
_____________________________________________________________________
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