Direct Access Eus Referral printable pdf download

UNIVERSITY OF MICHIGAN HEALTH SYSTEM

PROCEDURE REQUESTED:

DIRECT ACCESS EUS REFERRAL

! EUS

Phone: (877) 334-2943

! EUS with FNA

Fax: (734) 998-2323

! Other:

Website:

PATIENT NAME: ___________________________________________________________ DOB: _______________________

ADDRESS (City/State/Zip): ________________________________________________________________________________

Phone: ______________________________________________ ! Home

! Mobile

! Work

! Other

______________________________________________ ! Home

! Mobile

! Work

! Other

Insurance: ______________________________________________________________________________________________

REFERRING PHYSICIAN: ________________________________________________________________________________

ADDRESS: ____________________________________________________________________________________________

PHONE: ______________________________________________FAX: ____________________________________________

PRIMARY CARE PHYSICIAN: _____________________________________________ PHONE: ________________________

DIAGNOSIS:

REASON FOR PROCEDURE:

PREFERRED ENDOSCOPIST

(optional):

To expedite care, please fax the following records along with this requisition:

Recent History & Physical with medication list, Labs, and other relevant records

•

Most recent endoscopy reports (along with pathology reports if done)

•

Ultrasound or MRI/MRCP, if applicable

•

CT and/or PET scan***

•

***Patients referred for Esophageal Cancer staging need to have either a prior abdominal CT or PET scan and the

reports MUST BE included in the faxed records.

ARE EXCLUSIONS PRESENT? Please check the appropriate boxes.

REVIEWED.

Exclusions will prompt review by our nursing staff but will not prevent your patient from having a procedure.

! Age > 80 years

! Pregnancy

! MI/Angina/severe CHF w/in 6 mo

EXCLUSIONS

! BMI > 50

! Dialysis

! Treatment with any anticoagulant

PRESENT.

! Use of home oxygen

! Sleep apnea

! Coagulopathy, hereditary hemorrhagic

! Anemia with HCT < 20%

! Unable to provide consent

disorder, etc.

[INR >1.5 &/or Plts <75K]

! Suboxone

! ICD (defibrillator)

! Drug-eluding stent within the past year

_______________

Ordering

! Chronic high-dose narcotic use ! Aortic stenosis

! Pulmonary hypertension

Provider Initials

! Use of insulin

! Pacemaker

TO SCHEDULE: FAX completed form to (734) 998-2323. We will contact the patient.

UMHS • Medical Procedures Unit • March 2016

UNIVERSITY OF MICHIGAN HEALTH SYSTEM

DIRECT ACCESS EUS REFERRAL

Direct Access Eus Referral

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