Chelsea and Westminster Hospital
NHS Foundation Trust

The Denise Kilmarnock Endoscopy Unit
369 Fulham Road, London, SW1O 9NH
Tel: 020 8746 8193 Fax: 020 8237 5171

GP REQUEST FORM (PLEASE USE BLOCK CAPITALS AND BLACK INK)

Patient Details	GP Details	
Surname	«PATIENT_Surname»	Surname	«PATIENT_Registered_GP»	
Forenames	«PATIENT_Forename1» «PATIENT_Forename2»	Practice Address
	«PRACTICE_BlockAddress»	
D.O.B	«PATIENT_Date_of_Birth»	Phone	«PRACTICE_Main_Comm_No»	
Address	«PATIENT_BlockAddress»
	Fax	     	
Home phone	«PATIENT_Main_Comm_No»
	Practice code	     	
		
NHS No	«PATIENT_Current_NHS_Number»	

Investigation Required	
Flexible Sigmoidoscopy 		Upper G.I. Endoscopy 		
Urgent 		Non-Urgent 		

All referrals will be triaged by a consultant prior to any investigation, so please provide as much information as possible. Please note that all colonoscopy referrals should be referred directly to an outpatient clinic. 

Clinical Details
 (Please see reverse of this form)
     	

Patient’s General Health	
Does the Patient Have: 	Ischaemic Heart Disease 	Yes    No  
	Present Medication: 
«REPEATS»
     	
	Valvular Heart Disease	Yes    No  		
	Diabetes	Yes    No  		
	Respiratory Disease	Yes    No  		
Is the Patient:	Immunocompromised	Yes    No  	Drug Allergies: «DRUG_ALLERGY»	
Is there any other serious illness:	Yes    No  		
Details      		

Hospital Follow Up Care	
** Hospital Follow Up care will not be arranged unless you indicate what you are prepared to authorize in this section
	
Standard Follow Up Post Endoscopy	Yes    No  	
Urgent Follow Up Post Endoscopy 
If required by endoscopy findings	Yes    No  	
Please indicate which consultant the patient should be referred to:	Dr.      	
NOTE. In the event of the patient requiring URGENT treatment following the endoscopy, you will be contacted by an Endoscopy Unit doctor	

Investigation requested by (Print Name):      

Signed:                                                                               Date: «SYSTEM_Date»
	
POST / FAX THIS FORM TO THE ADDRESS / NUMBER ABOVE
Help us help you — Please write neatly and give us all the details

Chelsea and Westminster Hospital
NHS Foundation Trust

The Denise Kilmarnock Endoscopy Unit
369 Fulham Road, London, SW1O 9NH
Tel: 020 8746 8193 Fax: 020 8237 5171

INDICATIONS FOR ENDOSCOPY

1)	Upper G.I. Endoscopy

(a)	Upper abdominal pain with clinical features to suggest serious underlying disease, e.g.: weight loss, anaemia or palpable mass.
(b)	Upper abdominal pain which persists or recurs following a trial of therapy including H2 receptor antagonists.
(c)	Dysphagia, ideally preceded by barium swallow.

2)	Flexible Sigmoidoscopy

(a)	Restricted to the investigation of fresh blood per rectum when not immediately attributable to anal source.

PLEASE FILL IN THIS FORM IN A NEAT AND LEGIBLE MANNER, ENSURING ALL INFORMATION IS PROVIDED - ESPECIALLY UP-TO-DATE CONTACT DETAILS FOR THE PATIENT.