REQUEST FOR FLEXIBLE SIGMOIDOSCOPY
TO:
PATIENT DETAILS
Admissions Secretary for Endoscopies
Royal National Hospital for Rheumatic Diseases
Upper Borough Walls
BATH BA1 1RL
Surname:
Tel: 01225 473 401
Fax: 01225 462 599
First Name
D.O.B.
NHS No:
Address:
Diagnostic Unit – Dr A.Griffiths
Tel: 01225 473 409
Fax: 01225 473 463
Post Code:
Tel.
FROM:
Dr.
Address:
Post Code:
INDICATIONS :
EXCLUSIONS
Tel.
Signature
Rectal Bleeding
YES
NO
Possible Rectal Mass
YES
NO
Peri-anal Pain
YES
NO
HISTORY
Persistent change in bowel habit (>6 wks)
Iron deficiency anaemia
Consider referral for Colonoscopy
Abdominal pain
Relevant Other Medical History:
Heart valve replacement
YES
NO
Other reason for prophylactic antibiotic:
Warfarin
Medication
Priority
YES
Allergies
Urgent
Routine
You can download this form from the RNHRD website:
http://www.rnhrd.nhs.uk/departments/endoscopy/flexible_sigmoidoscopy.htm
Referral forms can be sent either by fax or post (details above), or by email to referrals@rnhrd.nhs.uk

NO