Referring Physician
Non-UAB Referring Physician Name
(Required)
First
Last
Contact Name
(Required)
First
Last
Office #:
(Required)
Fax #
(Required)
Office Email
Patient PCP Known?
Yes
No
PCP Name
(Required)
First
Last
Contact Name
(Required)
First
Last
Office #
(Required)
Fax #
(Required)
Patient Information
Patient Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Social Security Number
SSN needed to create a UAB medical record. All information is transmitted securely. If patient is unwilling to provide their social, you may enter 9's.
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Alternate Phone
(Required)
Email
(Required)
Insurance Information
Primary Name
(Required)
Hidden
Policy #
Policy#
(Required)
Hidden
Group #
Group#
(Required)
Secondary Name
Hidden
Policy #
Policy#
Hidden
Group #
Group#
Request Procedure
Diagnosis/Indication for Procedure
(Required)
Please check requested procedure
(Required)
Endoscopic Ultrasound
Rectal Endoscopic Ultrasound
Endoscopic Ultrasound with Pseudocyst Drainage
Endoscopic Ultrasound / Fine Needle Aspiration
Endoscopic Ultrasound / Pelvic Abscess Drain
EGD
EGD with EMR
EGD with ESD
Colonoscopy
Colonoscopy with EMR
Colonoscopy with ESD
Flex Sigmoidoscopy
Flex Sigmoidoscopy with RFA
ERCP
ERCP with Laser Lithotripsy
EGD with RFA
EGD with PEG
EGD with PEG/J
ERCP/Spyglass
Endoscopic Ultrasound/Celiac Block
Upper Luminal Stenting
Lower Luminal Stenting
Antegrade Double Balloon Enteroscopy
Retrograde Double Balloon Enteroscopy
Double Balloon Enteroscopy with Direct Percutaneous Jejunostomy Placement
NOTE: If the procedure requested is EUS, EUS/FNA or EUS/drainage, the actual images must be sent via PCS or on a CD to UAB GI Lab 619 19th Street South Birmingham, AL 35294.
Notes regarding requested procedure
Allergies
(Required)
Prior Endoscopies
(Required)
Yes
No
Prior Endoscopies type and date performed
(Required)
MM slash DD slash YYYY
History of gastric bypass, Billroth or Roux-en-Y
(Required)
Yes
No
If Yes, which procedure
Note: Patients with altered anatomy, if ERCP being ordered, would require Double Balloon Enteroscopy/ERCP
Diabetes
(Required)
Yes
No
If Yes, what type and medications?
Asthma
(Required)
Yes
No
Emphysema
(Required)
Yes
No
COPD
(Required)
Yes
No
Home Oxygen
(Required)
Yes
No
Obstructive Sleep Apnea
(Required)
Yes
No
CPAP machine
(Required)
Yes
No
Note: If yes then CPAP must be brought to hospital with the patient.
Does patient see a Cardiologist?
(Required)
Yes
No
If yes, Physician Name
First
Last
Office #
Hypertension
(Required)
Yes
No
Echo
(Required)
Yes
No
Note: If yes, please send copy with records.
CAD
(Required)
Yes
No
CABG
(Required)
Yes
No
If Yes, date of procedure
MM slash DD slash YYYY
CHF
(Required)
Yes
No
MI
(Required)
Yes
No
LVAD
(Required)
Yes
No
Cardiac Stents
(Required)
Yes
No
If yes, Year(s)
Pacemaker/Defibrillator
(Required)
Yes
No
If yes, Make/Model
Note: If yes, please include Pacemaker/Defibrillator card with records or patient must bring card with them.
Recent Hospitalizations
(Required)
Yes
No
If yes, admitted for
All current medication(s)
If not otherwise documented in patient records.
Blood Thinners
(Required)
Yes
No
If yes, list blood thinners: Coumadin, Plavix, Aspirin, Fish Oil, etc.
PATIENT MUST HAVE CURRENT HISTORY & PHYSICAL OR THE LAST CLINIC VISIT NOTES. Please fax or upload all records that correspond to the above marked conditions including:
Patient Demographics
Pathology Reports
CAT Scans/MRI/MRCP
Current Lab Work
Abdominal Ultrasounds
Endoscopy Reports
Please upload all records listed above.
Max. file size: 8 MB.