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Peterborough Community Endoscopy ServiceUnit Address: 6-10 Thistlemoor Road, New EnglandPeterborough PE1 3HPPatient Referral Centre Contact Number: 0845 437 0342Upper Endoscopy - Referral FormPatient NameDate of birthAddressGP NameAddressTel No:Mobile:NHS NumberDate of ReferralPostcodeTel NoFax NumberFaceal HP antigen must be tested before endoscopy referral. The antigen clears aftereradication of HP. (Unless urgent investigation required.)A period of Test and Treat may well avoid an unnecessary endoscopy and is recommended by theNICE guidelinesResult of Faecal HP antigen____________________________________________Without results, patients will not be offered a date and referrals will be returnedUrgent: This procedure is not a replacement for the 2 week cancer referralDysphagiaWeight lossVomitingAnaemiaSoon: Over 55yrsNew symptoms of:Continuous or persistent DyspepsiaHeartburnReflux symptomsUnexplained upper GI symptomsRoutinePoor symptom response to test and treatPoor symptom response to lifestyle adviceUnder 55's please summarise need for test outside of NICE guidelinesMedicationOther DiseasesPrevious InvestigationsWhat to donowThis form should be faxed immediately to: 0845 437 0343.Your patient will not be offered an appointment until the fax is received.

Peterborough Community Endoscopy ServiceUnit Address: 6-10 Thistlemoor Road, New EnglandPeterborough PE1 3HPPatient Referral Centre Contact Number: 0845 437 0342Further DetailsWhat to donowThis form should be faxed immediately to: 0845 437 0343.Your patient will not be offered an appointment until the fax is received.