Choose and Book Referral - InHealth

Inhealth Endoscopy Ltd–West Oxfordshire Direct Access Community Endoscopy ServiceGastroscopy Request FormPlease fax this referral to 0845 4370343ALARM SYMPTOMS: Patient with any of these symptoms should be referred into appropriate 2WWserviceDysphagiaEpigastric massUnexplained, persistent new dyspepsia, aged >55 yrsUnintentional weight lossPersistent vomitingIron deficiency anaemia with no obvious causeObstructive jaundicePatient DetailsSurname:Forename:Referrer detailsReferring GP:Usual GP:Address:Address:Postcode:Home tel:Daytime tel:Date of BirthPostcode:Tel:Fax:NHS Number:INVESTIGATION REQUEST DETAILSCurrent RequestGastroscopy (Upper GI)Patient had previous endoscopy? Yes No Date (DD/MM/YYYY):If yes, what type of previous endoscopy? Gastroscopy Flexi Sigmoidoscopy ColonoscopyReason for request:Relevant clinical history:Page 1 of 2Referral template for Upper GI – Oxfordshire - IEL 20130902

Inhealth Endoscopy Ltd–West Oxfordshire Direct Access Community Endoscopy ServiceGastroscopy Request FormMEDICAL INFORMATIONNote: If the patient requires sedation, they must have an escort home and have observation overnightDoes the patient have capacity to give informed consent? Yes NoIs this patient diabetic?Yes NoIf yes, is the patient Insulin dependent?Yes NoIs the patient on Warfarin? Yes No Duration:Is the patient on Clopidogrel? Yes No Duration:If you have answered ‘yes’ to any of the questions above, please ensure that you include any additional relevantclinical information above.H Pylori status: Positive Negative Not knownNSAID: Yes No Duration (weeks): Must continue: Yes NoPPI/H2 antagonist: Yes No Duration (weeks): Patient responded Yes NoENDOSCOPY SITEWindrush Medical CentrePage 2 of 2Referral template for Upper GI – Oxfordshire - IEL 20130902