UTMB Endoscopy Referral Form free printable template

Fill in or paste TMB label ENDOSCOPY REFERRAL FORM PATIENT INFORMATION Date: Name: UH #: DOB: Address: Referring MD: Dr. Telephone #: Fax #: Email: Telephone # : Home: Work: PROCEDURE (please circle

How to fill out endoscopy form utmb fillable

How to fill out UTMB Endoscopy Referral Form

1. Obtain the UTMB Endoscopy Referral Form from the UTMB website or your healthcare provider.
2. Fill in the patient's personal information, including name, date of birth, and contact information.
3. Indicate the referring physician's name and contact information.
4. Specify the type of endoscopic procedure required (e.g., upper endoscopy, colonoscopy).
5. Provide relevant medical history and any previous endoscopic procedures.
6. List the indications for the referral, stating the symptoms or conditions that necessitate the procedure.
7. Include any pertinent lab results, imaging studies, or other relevant documentation.
8. Review the form for accuracy and completeness.
9. Submit the completed form to the appropriate department or clinic at UTMB.

Who needs UTMB Endoscopy Referral Form?

1. Patients experiencing gastrointestinal symptoms such as chronic abdominal pain, gastrointestinal bleeding, or unexplained weight loss.
2. Individuals with a family history of gastrointestinal diseases who require preventive screening.
3. Patients who have received a recommendation from their primary care physician or specialist for an endoscopic evaluation.

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What is UTMB Endoscopy Referral Form?

The UTMB Endoscopy Referral Form is a document used to refer patients for endoscopic procedures at the University of Texas Medical Branch (UTMB) healthcare system.

Who is required to file UTMB Endoscopy Referral Form?

Healthcare providers such as physicians or specialists who recommend endoscopic procedures for their patients are required to file the UTMB Endoscopy Referral Form.

How to fill out UTMB Endoscopy Referral Form?

To fill out the UTMB Endoscopy Referral Form, the referring provider must provide patient information, medical history, the type of endoscopy requested, and any relevant clinical details that justify the referral.

What is the purpose of UTMB Endoscopy Referral Form?

The purpose of the UTMB Endoscopy Referral Form is to streamline the referral process for patients requiring endoscopic evaluations and to ensure that all necessary information is provided to facilitate proper scheduling and treatment.

What information must be reported on UTMB Endoscopy Referral Form?

The information that must be reported on the UTMB Endoscopy Referral Form includes patient demographics, clinical indications for the endoscopy, relevant medical history, and any prior diagnostic tests or treatments related to the condition.