You are requesting a procedural service which does not constitute the assumption of care and/or consultative services. If
these services are requested please refer your patient to Gastroenterology and Hepatology.
The referring provider is also responsible for prescribing the preparation for colonoscopy or sigmoidoscopy.
If no exclusions--FAX THE COMPLETED SHEET TO 559-4933 AND CALL 559-8503 TO
SCHEDULE AFTER FORM IS FAXED.
PATIENT NAME
CLINIC NAME
MRN
CLINIC PHONE NUMBER
REFERRING/ATTENDING PHYSICIAN
LOCATION CHOICE:
TNMC _______ VILLAGE POINTE ______ (Mondays (Dr. Volentine) or, Fridays (Dr. Hutchins)
**EXCLUSION Criteria: Please refer to **exclusion criteria** section first. If any apply—STOP! Do
NOT complete and fax form—Patient MUST BE SEEN IN GI CLINIC- Please Call 559-6040 to
schedule this appointment.

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
Age greater than 80
Congestive Heart Failure
MI or Chest pain within last 12 months
COPD (FEV less than 1.25), Home oxygen use)
Obstructive sleep apnea (Requiring CPAP or
oxygen)
 NSAIDs
 Aspirin
 Insulin/oral hypoglycemics
 Coagulopathy (INR greater than 2) Or Bleeding
Disorder
 Platelet count less than 75,000
 Anticoagulation (Coumadin, Heparin, Lovenox)
 On 3 or more of the following meds:
Benzodiazepines, Narcotics, Antipsychotics, history
of sedation complication or intolerance to
conscious sedation
PREFER PATIENT TO HOLD/STOP 5-7 DAYS PRIOR TO
PROCEDURE
REFERRING PROVIDER TO ADJUST DOSE AS NECESSARY
Indication(s):
EGD (upper endoscopy)
 Persistent abdominal pain/dyspepsia
 Dysphagia or odynophagia
 Esophageal reflux symptoms that are persistent or
recurrent despite appropriate therapy
 Persistent nausea/vomiting
 Persistent/chronic diarrhea
 GI bleeding (iron deficiency anemia or positive fecal
occult blood)
 Barrett’s screening
 Follow-up gastric ulcer
Flexible Sigmoidoscopy
Indication____________________________________
Colonoscopy (lower endoscopy)
Colorectal cancer screening







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
Average risk (no family history, age
greater than 50)
History of colon polyps
Family history of colon cancer
Post colon cancer resection
 1 year post diagnosis, then every 3-5 years
thereafter if negative
Inflammatory bowel disease
Persistent/chronic diarrhea
Altered bowel habits
Abnormal barium enema/CT colography
GI bleeding (hematochezia, fecal occult blood, iron
deficiency anemia)
 Other________________________________