Colon Screening Program: Colonoscopy Referral Form

PHN NUMBERC olon Screening Program: Colonoscopy Referral FormComplete Provider and Patient In fo rmationPATIENT LAST NAMEDOBOTHER HEALTH NUMBER ( RCMP, MILITARY)PATIENT FIRST NAMESEXCITY/TOWNPOSTAL CODEREFERRAL DATEPATIENT TELEPHONE NUMBERSPROVINCEORDERING PHYSICIAN(ADDRESS, MSC PRACTITIONER #)COPY TO MSC # & NAMEPHYSICIAN SIGNATUREP atients are excl uded from the Colon Screening Program ( Screening col onoscopy and fe cal immunochemical test (FIT)) if they: Are up to date with Colonoscopy scre ening or have had a normal FIT re sult in the past two years (average risk patients). Have a personal history of colorectal cancer, ulcerative colitis or Crohn s diseas e. These patients should continue to obtain ca re through their special ist or health ca re provider. Curr ently have symptoms, rectal bleeding, persistent change in bowel habits, abdominal pain, unintentional weight loss or iron deficiency anemia.

PHN NUM BER Colon Screening Program: Colonoscopy Referral Form Complete Provider and Patient Information PATIENT L AST NAME DOB OTH ERAL NU M(E . GRCMP , IY )

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  Programs, Form, Screening, Referral, Colonoscopy, Colons, Colon screening program, Colonoscopy referral form

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