Direct Access Referral Form For Physicians Only
Colonoscopy and EGd (esophagogastroduodenoscopy)
Which patients are eligible for direct access endoscopy?
Medically stable adult outpatients with specific accepted indications for endoscopy (see checklists below) can be referred through Direct Access Endoscopy without formal GI consultation.
Which patients are not eligible?
(1) Unstable or acutely bleeding patients or those with contraindiction for endoscopy such as known or suspected perforation or high grade obstruction, severe or acute diverticulitis, fulminant colitis, uncorrectable coagulopathy or thrombocytopenia, unstable cardiac or pulmonary conditions.
(2) Patients requiring advanced endoscopic procedures (such as photodynamic therapy, argon plasma coagulation, cryotherapy, mucosal resection, saline-assisted piecemeal polypectomy, laser, dilation, EUS-guided interventions such as celiac plexus block/neurolysis, pseudocyst drainage, etc.).
Please fill in the the form below and click Submit. You must include the practice email and the patient's name.
For the indications, enter a "Y" if the indication is present; you can leave other indications blank if they do not apply.
FILLING OUT THIS REQUEST FORM ONLINE DOES NOT MAKE OR GUARANTEE AN APPOINTMENT
OUR OFFICE STAFF WILL FOLLOW UP BY TELEPHONE TO MAKE THE ACTUAL APPOINTMENT
COLONOSCOPY INDICATIONS (please enter "Y" for applicable indications)
EGD INDICATIONS (please enter "Y" for applicable indications)