Upper GI Endoscopy referral form
Priority:
urgent
routine
We will contact your patient by telephone to offer an appointment. Please ensure we
have a contact number, preferably a mobile number, so that treatment is not delayed.
Mr/Mrs/Miss
Surname
First name(s)
NHS number
Gender
Address
Referral criteria
55 or over with unexplained and
persistent RECENT onset
dyspepsia
Dyspepsia, or upper GI
symptoms, at any age if
associated with a strong family
history of significant upper GI
disease
Upper GI symptoms which have
not responded to symptomatic
trial of dyspepsia management.
This should include HP testing
Unexplained worsening of
dyspepsia with one of the
following risk factors – Barretts/
pernicious anaemia/previous
peptic ulcer surgery
Asymptomatic, iron deficiency
anaemia in men and postmenopausal women
HB
MCV
Ferritin
Patients with positive coeliac
antibodies, requiring confirmatory
upper GI endoscopy and biopsy
Recent hospital admission
requesting GP to arrange upper
GI endoscopy
Progressive dysphagia
Persistent vomiting
Patients requiring Barrett’s
surveillance
Signature of GP:
Date:
Date of birth
Referring GP
Registered GP
Practice code
Practice address
Yes
No
HP eradication
Yes
Current treatment
PPI
Aspirin
NSAIDS
Warfarin
Other significant medication
Allergies
Patients with the following are not
suitable for open access endoscopy
and should be referred to a
gastroenterology clinic:







Where endoscopy will not alter
management
Myocardial infarction within the
past eight weeks
Moderate or severe cardiac or
respiratory disease
Elderly/frail patients
Patients who are receiving
chemotherapy
Immunosuppressed patients
Patients who cannot give
informed consent to the
procedure
No