Pediatric Gi Referral Form - Unm Hospitals

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Pediatric Gastroenterology, Hepatology and Nutrition
Referral Form
Phone: (505) 272-4928
Fax: (505) 925-2429
DATE: __________________________________________________________
PATIENT INFORMATION (PLEASE PRINT & FILL OUT ALL BLANKS)
Last Name
First Name & MI
Age
Date of Birth
Male
Female
Street Address & City
State
Zip Code
Parent/Guardian
Home #
Work #
Cell #
REFERRING PHYSICIAN INFORMATION
Referring Physician
Name of Contact Person
Office Phone #
Office Fax #
***CLINICAL INFORMATION***
All referrals MUST submit a DEMOGRAPHIC SHEET, INSURANCE INFORMATION, CLINICAL NOTES,
GROWTH CHART, LABS, X-RAYS, and TESTS & PROCEDURES PERTINENT to referring issue.
Referring Issue
Required Information To Be Faxed With This Form
Abdominal Pain
Duration:
<1 week
1-2 weeks
>2 weeks
Diarrhea
Weight loss:
none
<5%
>5% to 10%
>10%
Duration:
<1 week
1-2 weeks
>2 weeks
CBC, PT, inr
Rectal Bleeding
Hemoccult results:
Positive
Negative
Present and past treatment:
GER
Most current KUB (send films or a disk)
Constipation/Encopresis
Duration:
Treatments tried:
Increase fiber
Miralax
Other:
TSH, Free T-4, IgA level, TTG IgA. ** Please send growth charts **
Poor Growth/Failure to Thrive
Treament:
HCV-PCR (Hep C referral only), LFT, PT/INR, Blood Pressure measurements
Hepatitis C
Liver Disease/Hepatitis A,B
Lipid Panel, fasting glucose, LFT, Hgb A1C, fasting insulin level, TSH, FT4
Dyslipidemia
Fatty Liver Disease (NAFLD)
Jaundice
Total & Direct Bilirubin, GGT, Liver panel
Duration:
<1 week
1-2 weeks
>2 weeks
Fecal Calprotectin, CRP, ESR, CBC, Diff, Complete Metabolic panel including Liver panel
IBD (Crohn’s & Colitis)
Hemoccult results:
Positive
Negative
Duration:
<1 week
1-2 weeks
>2 weeks
** Please send growth charts **
Present Treatment:
Feeding Disorder
Intestinal Rehabilitation/Short Gut
Copy of surgical report & discharge summary from hospital, or historical patient notes
TTG IgA and IgA level
DO NOT CHANGE DIET UNTIL SEEN BY PEDIATRIC GI
Celiac Disease
Documentation of dysmotility (e.g. gastric emptying study) OR frequency, length of time, and treatment
Motility (e.g. IBS, gastroparesis, post-GI surgical
already tried in History & Physical
Treatment:
Other:
After faxing this information, please have the family call our office to schedule an appointment. If an urgent appointment is needed
the Health Care Provider can reach the on-call Pediatric Gastroenterologist by calling the PALS line (1-888-UNM-PALS).

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