Evaluation Of Abnormal Pap And/or Colposcopy-General Obstetrics & Gynecology-Referral Form printable pdf download

Phone: (603) 653-9300

Fax: (603) 650-0901

Referral Form

Evaluation of Abnormal Pap and/or Colposcopy

General Obstetrics & Gynecology

To schedule your patient, please include any pertinent records including Pap smear results,

pathology reports, or relevant office notes unless available in CIS.

Patient Name: ________________________________________________________ MRN: ____________________________

Mailing address: ___________________________________________________________________________________________

Home Phone: ______________________ Work Phone: ______________________ Cell Phone: ________________________

DOB: ________________________________________________________________ *Age: ____________________________

*For women 20 years or younger: if Pap is ASCUS or LSIL, repeat Pap in 12 months (even if HPV positive); if that Pap (#2) is

ASCUS or LSIL, repeat again in 12 months; if repeat (#3) is still abnormal, refer for colposcopy.

Current Pap Smear:

Date of Pap Smear: _______________________________

Normal Pap with persistent High Risk HPV positive

HSIL

ASCUS with positive High Risk HPV

AGUS

LSIL

Other: ______________________________________

Prior Treatment for Abnormal Pap?

Yes

If yes, please describe: ______________________________________________________________________________________

Is patient pregnant?

Yes

If yes, please provide EDD: __________________________________________________________________________________

Reason for Request (please check only one):

Consultation & Colposcopy: Colposcopy and other evaluative testing will be performed, if indicated.

We will follow up with the patient and formulate and execute treatment plans. The patient will be returned to you for

decisions regarding all other aspects of her care, including follow-up pap smears and other gynecological care.

Other (describe): _____________________________________________________________________________________

Preferred Day of Week: __________________________________________________

AM / PM

Please note: we strive to meet these requests, but may not always be able to do so.

Referring Provider: ____________________________________________________ Office # __________________________

Contact Person: ________________________________________________________ Fax #: ____________________________

Address: _________________________________________________________________________________________________

May we send notes to you via Hitchcock email?

Yes

Is the patient aware of this referral so she may be contacted by our office?

Yes

Would your office like notification of this appointment?

Yes

1 Medical Center Drive | Lebanon, NH 03756 | Tel: (603) 650-5000 |

Rev. 3

/20/08

Evaluation Of Abnormal Pap And/or Colposcopy-General Obstetrics & Gynecology-Referral Form

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