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CHARTWELL GUT HEALTH

Bowel Cancer Screening
Conditions We Treat
Colonoscopy
Gastroscopy
Flexible Sigmoidoscopy
Where to Find Us

Direct Access Endoscopy Referral

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Direct Access Endoscopy Form

Patient Information

Patient Contact Details

First Name

Last Name

Date of Birth

NHS Number

Patient Address

Home Telephone Number

Work Telephone Number

Mobile Phone Number

Referring GP

Date of referral

GP Address

Procedure

Referral Type

Indication

Reason For Referral (Select all applicable)

Dyspepsia

Persistent Vomiting

Epigastric mass

Fe deficiency anaemia

Unexplained weight loss

Dyspepsia in Barrett’s & Peptic ulcer surgery >20yrs

Barrett’s Surveillance

Nausea

Unexplained rectal Bleeding

Unexplained diarrhoea

Colorectal Cancer

Fe deficiency

Anaemia

CIBH

Abdominal

Bright red rectal bleeding

Colitis Assessment

Haemorrhoid treatment

Any other significant Symptoms

Previous Medical History

Fitness for Procedure

Unstable Angina

Severe COPD

IDDM Colonoscopy

MI last 3 months

Active Chest Infection

Controlled Hypertension

Free Text

Heart Failure and Chronic Kidney Disease (eGFR<30ml/min) – Please provide latest EGFR &Creatinine for Colonoscopy

Current Medication

Warfarin

Clopidogrel

Aspirin

Iron Supplements

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THE CHARTWELL HOSPITAL

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