Get the free Screening colonscopy referral form - Hamilton Health Sciences
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JOSEPH BRANT MEMORIAL HOSPITAL 1230 North Shore Blvd, Burlington, ON L7S 1W7 SCREENING COLONOSCOPY REFERRAL FORM Once fully completed, fax to 905-681-4961 * The patient will be contacted directly
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How to fill out screening colonscopy referral form
How to fill out screening colonscopy referral form:
01
Start by filling out your personal information accurately. This includes your full name, date of birth, address, contact number, and any other required details.
02
Next, provide your medical history. This may include any previous surgeries, medical conditions, allergies, or medications you are currently taking. It is important to be thorough and include any relevant information.
03
Specify the reason for the screening colonscopy referral. Indicate any symptoms or concerns that prompted the need for the procedure.
04
If applicable, provide details about your primary care physician or referring doctor. This includes their name, contact information, and any other necessary details.
05
Make sure to sign and date the referral form. This confirms your consent and understanding of the procedure.
Who needs a screening colonscopy referral form:
01
Individuals above a certain age, usually 45 or 50 years old, as recommended by healthcare guidelines, may need a screening colonscopy referral form.
02
People with a family history of colorectal cancer or polyps may be advised to undergo screening through a referral form.
03
Patients with symptoms such as rectal bleeding, persistent abdominal pain, unexplained weight loss, or changes in bowel habits may require a referral for a screening colonscopy to investigate potential causes.
Note: It is important to consult with your healthcare provider to determine if you meet the criteria for a screening colonscopy referral form.
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What is screening colonscopy referral form?
The screening colonscopy referral form is a document used to refer patients for a colonoscopy procedure as part of a screening program.
Who is required to file screening colonscopy referral form?
Healthcare providers are required to file the screening colonscopy referral form for patients who meet the screening criteria.
How to fill out screening colonscopy referral form?
The screening colonscopy referral form can be filled out by providing patient information, medical history, reason for referral, and any relevant test results.
What is the purpose of screening colonscopy referral form?
The purpose of the screening colonscopy referral form is to ensure that patients receive appropriate screening for colon cancer and other colorectal conditions.
What information must be reported on screening colonscopy referral form?
The screening colonscopy referral form must include patient demographics, medical history, screening eligibility criteria, referring provider information, and any relevant test results.
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