Referral Form - Advance Endoscopy & Specialist Centre

All patients must be referred by a physician.

Date

Patient's Name

First

Last

Referring Physician

Patient's Address or Label

Physician's Address or Stamp

Health Card No.

Gender

Male

Female

Physician Referring Number

Date of Birth

Daytime Phone

Evening Phone

Physician's Phone No.

Physician's Fax No.

EXCLUSION CRITERIA - Check all that apply - (Patients should be referred to hospital based physician)

CARDIOVASCULAR

Recent Ml <6 months OR unstable angina)

CHF

SEVERE VALVULAR HEART DISEASE

PULMONARY

SEVERE COPD / EMPHYSEMA (ON HOME 02)

SEVERE SLEEP APNEA (CPAP)

MORBID OBESITY (BMI)

GI/LIVER

BRISK GI BLEEDING/ MELENA

DE COMPENSATED LIVER DISEASE

OBSTRUCTIVE JAUNDICE/ CHOLANGITIS

OTHER

CURRENT PREGNANCY

NON-AMBULATORY PATIENT

RENAL

DIALYSIS PATIENT

Reason For Referral

(please check all that apply)

URGENT

CONSULTATION

FOLLOW UP

GASTROSCOPY

COLONOSCOPY SIGMOIDOSCOPY

ANORECTAL & OTHERS

HAEMORRHOIDS

SKIN TAGS/ LESIONS

FISSURE - IN ANO

SEBACEOUS CYST

Patient's Preference

MALE PHYSICIAN

FEMALE PHYSICIAN

NO PREFERENCE

NOTE: Kindly include all the relevant reports for patient along with the referral ( ECG, bloodwork, etc )

MEDICATIONS

LIST ALL MEDICATIONS

Medical History

Hx of adverse reaction to sedation /anaesthesia

Patient uses prophylactic antibiotics

Diabetes Mellitus: Type I or Type II

Prosthetic heart valve

Last serum Creatinine

Allergies

Abnormal renal function

Note: Please provide a copy of this referral form to the patient. Please advise the patients to call and fax their
relevant clinic for immediate appointment.

Please ask patient to bring interpreter, if patient does not speak English.

Please indicate if you require additional referral forms

Note: You can also download and print the referral form from our website:

EMAIL THIS FORM TO

Mississauga

Toronto

Bowmanville

Please notify us three (3) business days prior to the appointment date, otherwise a cancellation fee will be applied