Get Utmb Endoscopy Referral Form

The UTMB Endoscopy Referral Form is a crucial document for scheduling endoscopy procedures. This guide will assist you in successfully completing the form online, ensuring all necessary information is provided for efficient processing.

Follow the steps to complete the UTMB Endoscopy Referral Form online.

1. Use the ‘Get Form’ button to access the UTMB Endoscopy Referral Form and open it in your preferred editor.
2. Fill in the patient information section, including the date, name, unique hospital number (UH #), date of birth (DOB), and address.
3. In the referring MD section, write the name of the physician who is referring the patient, followed by their telephone number, fax number, and email address for communication.
4. Input the patient's home and work telephone numbers to ensure contact availability.
5. In the procedure section, circle the appropriate option for the procedure being requested: Colonoscopy, EGD, EUS/EGD, or EUS/Rectal.
6. In the indication for exam section, circle the reason for the exam. If applicable, provide additional details under 'Others'.
7. Describe any pertinent medical history that may affect the procedure in the relevant section.
8. Answer the yes/no questions regarding the patient’s ability to self-consent, discharge arrangements, medication instructions, and any relevant medical conditions. If a question requires further details, provide that information as necessary.
9. List any allergies and current medications the patient is taking, ensuring all information is accurate.
10. If applicable, circle all relevant patient conditions such as CHF, cirrhosis, or others that may influence the procedure.
11. For direct endoscopy requests, ensure you have the fax number available for submission and remind the patient to call the scheduled number.
12. Complete the financial information section as required, including insurance details, relevant contacts, and policy information.
13. After filling out all sections, review the form for accuracy, then save your changes, download, print, or share the completed document as needed.

Complete the UTMB Endoscopy Referral Form online today to ensure prompt scheduling of your procedure.