Get the free Endoscopy request final-3-1 - Dartmouth-Hitchcock

One Medical Center Drive Lebanon, NH 03756 Section of Gastroenterology & Hepatology Phone: (603) 6505030 Fax: (603) 6505225 ENDOSCOPY REQUEST (Please either fax or mail) Requesting MD/provider: Blue

How to fill out endoscopy request final-3-1

How to fill out endoscopy request final-3-1:

1. Start by filling in the patient's personal information, such as their full name, date of birth, and contact information.
2. Next, provide details about the referring physician, including their name, specialty, and contact information.
3. Indicate the reason for the endoscopy request. Specify the symptoms or medical condition that necessitates the procedure.
4. Choose the type of endoscopy being requested, such as upper gastrointestinal endoscopy or colonoscopy. Provide any additional details or specific areas of interest.
5. Indicate the patient's medical history, including past surgeries, allergies, and current medications. This information helps the endoscopist assess any potential risks or complications.
6. Specify any special instructions or preparations required for the procedure. This may include dietary restrictions, medication adjustments, or necessary testing before the endoscopy.
7. Finally, review the completed form for accuracy and ensure all required fields have been filled out. Sign and date the form before submitting it to the appropriate department or healthcare provider.

Who needs endoscopy request final-3-1:

1. Patients experiencing gastrointestinal symptoms such as abdominal pain, difficulty swallowing, or persistent heartburn may need an endoscopy request.
2. Individuals with a family history of gastrointestinal diseases, such as colon cancer or Barrett's esophagus, may require an endoscopy for early detection or surveillance.
3. Patients with abnormal results from previous screenings or diagnostic tests, such as an abnormal CT scan or positive fecal occult blood test, may be referred for further evaluation through an endoscopy.
4. Individuals with chronic gastrointestinal conditions, such as Crohn's disease or ulcerative colitis, may require regular endoscopic monitoring to assess disease activity or progression.
5. Patients with liver or pancreatic disorders, such as cirrhosis or chronic pancreatitis, may require an endoscopy to assess organ function or perform therapeutic interventions.

Overall, endoscopy request final-3-1 is necessary for patients who exhibit gastrointestinal symptoms, have risk factors for gastrointestinal diseases, require further evaluation based on abnormal test results, or need monitoring and interventions for specific digestive disorders.

For pdfFiller’s FAQs

What is endoscopy request final-3-1?

Endoscopy request final-3-1 is a form used to request an endoscopy procedure for a patient.

Who is required to file endoscopy request final-3-1?

Healthcare providers such as doctors or specialists are required to file endoscopy request final-3-1.

How to fill out endoscopy request final-3-1?

Endoscopy request final-3-1 should be filled out with the patient's information, medical history, reason for the procedure, and any other relevant details.

What is the purpose of endoscopy request final-3-1?

The purpose of endoscopy request final-3-1 is to formally request an endoscopy procedure for a patient.

What information must be reported on endoscopy request final-3-1?

Information such as patient's name, date of birth, medical history, reason for the procedure, and any relevant test results must be reported on endoscopy request final-3-1.

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