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.

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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