Colon Screening Program: Colonoscopy Referral Form

1 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.

2 These patients should be referred to a special ist, no FIT re quired. Are on a definite surveillance plan thro ugh a special ColonoscopyRecommended for individuals, ages 50-74 (inclusive), at higher than average risk fo r develo pin g colorectal cancer, defined asOne first degre e relative with colorectal cancer diagnosed under the age of 60; or ,Two or more first degree re latives with colorectal cancer diagnosed at any age; or,A personal history of adenoma(s ) - attach previous col onoscopy and path ologyAge eligible patients (50-7 4 inclusive) who are not higher than avera ge ri sk should be referre d fo r the FIT using the StandardOutpatient Lab Requisition fo r Abnormal FITA bnormal FIT Result:Send form to BC Cancer Agency to Facilitate Referral to the Health AuthorityVisit nFax to: 1-604-297-9340orMail to:BC Cancer AgencyCol on Screening Program801-686 W.

3 BroadwayVancouver, BC V5Z1G1 Patient will be contacted by a patient coordinator in their Health Authority to arrange an assessment fo r communications are intended only for the use of the addressee and may contain information that is privileged and confidential. Any dissemination,distribution or copying of this communication by unauthorized individuals is strictly prohibited. If you receive this communication in error, please notify theColon Screening Program immediately by telephone at OF FIT TIFTLUSER RESULTng/mlSTEP 1 PATIENT ADDRESSYYYYMMDDYYYYMMDDSTEP 2 Confirm Eligibility and Select Indication for ColonoscopySTEP 3 Learn about the impor tance of col on : NOVEMBER2013 Attach FIT lab northern way of caring