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Get UTMB Endoscopy Referral Form

Work: PROCEDURE (please circle one): A) Colonoscopy B) EGD C) EUS/EGD D) EUS/Rectal INDICATION FOR EXAM (please circle): A) Colon cancer screening B) Others please specify: PERTINENT HISTORY (please describe): All of the following must be answered to assist us in scheduling the patient ASA.

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