Get Endoscopy Request Form - The Frist Clinic

Completing the Endoscopy Request Form is an essential step in coordinating your medical procedure. This guide provides detailed instructions to help you accurately fill out the form online, ensuring a seamless submission process.

Follow the steps to successfully complete your Endoscopy Request Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient’s name and date at the top of the form.
3. Provide contact information by filling in the home phone, work phone, and cell phone fields.
4. Enter the referring physician’s name along with their telephone number.
5. Note the fax numbers displayed for the required physicians. Indicate which physicians you wish to send the form to by checking the appropriate boxes.
6. Attach a legible copy of your insurance card(s) and include a demographic sheet. Ensure you follow any referral requirements as necessary.
7. Select the type of procedure by checking the appropriate box: Routine Screening, Colonoscopy, Flex Sigmoid, EGD, or Other. Provide a description if 'Other' is selected.
8. If applicable, indicate if the patient has a family or personal history of colon cancer or polyps.
9. For each procedure type selected, fill in the diagnosis information specific to that procedure.
10. If the patient has previously undergone a colonoscopy, record the year of that procedure.
11. Use the comments section for any additional information that may be relevant for the referring physician.
12. Sign the form with the referring physician’s signature, ensuring that a signature stamp is not used.
13. Once all sections are completed, save changes to the form, and consider downloading or printing it for your records.

Complete your Endoscopy Request Form online today to ensure timely and effective care.